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worth while, it must be remembered that it fallsinto the category of exploratory operations. Asine qua non of such an operation is that it shall dolittle harm to the organ explored, and hemisectionreceives no justification from .experiments in whichthe kidney was severely damaged in 4 cases out of12 cases, and largely atrophied in another.Nor does it seem that Lowsley’s technique is

noticeably less deleterious in its effects than the

ordinary operation in which mattress sutures are

used.

I am indebted to Dr. F. T. Ranson for suggesting theinvestigation, to Mr. R. V. Dent for the photographs, andto Mr. Henderson for the sections, and to Messrs. Davisand Geck Inc. for a supply of ribbon catgut.

BIBLIOGRAPHY

Hinman, Morrison, and Lee-Brown : Demonstration of Circu-lation, Jour. Amer. Med. Assoc., 1923, lxxxi., 172.

Lowsley, O. S. : Some New Developments in Renal Surgery,Southern Med. Jour., 1934, xxvii., 139.

Mimpriss, I. W. : Splitting the Kidney, THE LANCET, 1934,ii., 921.

Woollard, H. : Intravital Staining. Recent Advances inAnatomy, London, 1927, p. 114.

Clinical and Laboratory Notes

PERFORATED GASTRIC ULCER

RECOVERY IN A MAN AGED 81

BY T. ST. M. NORRIS, M.B. Camb.,M.R.C.P. Lond., D.P.H.

SENIOR ASSISTANT MEDICAL OFFICER, THE ARCHWAYHOSPITAL (L.C.C.), LONDON, N.

RECOVERY after perforated gastric or duodenalulcer appears to be rare in the aged. Schulein 1

describes two cases in which a man and a woman,both aged 76, died after operation. Speck 2 recordsone case of a woman aged 69 who survived for eightweeks after operation and then died of heart failure ;he also gives statistics of eight others all over the

age of 60, but does not mention their fate. Graves 3

describing eight cases between the ages of 60 and 70had a recovery in three of them ; while Gilmour andSaint, 4 in a series of sixty-four cases, give the age offive as over 60, the oldest male being 67 and theoldest female 69 ; only three of the sixty-fourfailed to recover. Read,5 Brown, and Scotson 7

also give statistics of perforation in patients overthe age of 60, but they do not give information aboutthe fate of individual patients.The case I describe seems worthy of record in

view of the patient’s age and his uninterruptedrecovery.On admission to the Archway Hospital the patient

gave a history of dyspepsia for the past two years, buthe had been comparatively well until the morning of hisadmission to hospital, when he had suddenly collapsedwith severe abdominal pain while engaged in sweepingout his room ; he had not vomited. He was an elderlyman with severe arterio-sclerosis. The pulse-rate was 116and the temperature 992° F. : although obviously in

. considerable pain he was not severely collapsed andwas able to give a clear account of himself. The abdomenmoved very little with respiration ; it was rigid throughout,and there was no liver dullness.The operation under general anaesthesia was begun

nine hours after perforation. The peritoneal cavity wasfound to contain gas and free fluid, and there was aperforation in the anterior surface of the stomach nearthe pylorus. This was closed with interrupted stitchesand reinforced with a piece of adjacent omentum. The

pouch of Douglas was drained by a tube through a supra-pubic stab wound. The patient’s convalescence wasuneventful and the wound healed by first intention.On discharge home 25 days after operation the scar

was sound and the patient walked well. When seen

again six months later he stated that he had rapidlygained strength ; he now looked after himself and

frequently walked 3-5 miles daily ; he had no dyspepsiaor inconvenience and eats a light mixed diet.The radiologist’s report on a barium meal reads : " The

stomach showed normal appearance except for some

irregularity on its lesser curve near the pylorus. Thelatter functioned well, and on pressure the duodenal cap,could be well filled ; no ulcer crater could be demonstratedeither in the stomach or the duodenum."

A reference to the records of Somerset Houseconfirms the age of the patient as 81.

My thanks are due to Dr. C. D. Agassiz, medical superin-tendent of the hospital, for permission to publish this case,and to Dr. F. G. Nicholas for his report on the barium meal.

REFERENCES

1. Schulein, M. : Deut. Zeits. f. Chir., 1921, clxi., 242.2. Speck, W. : Beitr. z. klin. Chir., 1923, cxxix., 537.3. Graves, A. M. : Ann. of Surg., 1933, xcviii., 197.4. Gilmour, J., and Saint, J. H. : Brit. Jour. Surg., 1932-33,

xx., 78.5. Read, J. C. : New York State Jour. Med., 1930, xxx., 591.6. Brown, H. P. : Ann. of Surg., 1929, lxxxix., 209.7. Scotson, F. H. : Brit. Med. Jour., 1933, ii., 680.

POLYSEROSITIS

BY O. K. G. GUYER, M.D. Edin.AND

F. B. SMITH, M.D. Camb.PATHOLOGIST TO THE ROYAL INFIRMARY, PRESTON

THE subject of polyserositis is complicated by theconfusion and complexity of nomenclature ; severalconditions clinically similar are included under thesame title. The term seems most suitable to describea chronic hyperplastic serositis of the pleural, peri-toneal, and, sometimes, pericardial cavities. Someof the synonyms are multiple serositis, Concato’sdisease, Pick’s disease (pericarditic pseudocirrhosisof the liver), diffuse chronic hyperplastic peri-hepatitis, chronic hyaline perihepatitis, chronicproliferative peritonitis, and Zuckergussleber ofCurschmann.Adherent pericarditis of known aetiology may end

with heart failure, chronic venous congestion of theliver, oedema of the lungs, pleural effusion, andascites, and yet be known by any of the above

names, particularly Pick’s disease. It does not,however, show the widespread, uniform picture ofserous hyperplasia and polyserositis described below,though it is not unusual to find sugar-icing of theliver, peritoneum, and pleura in a minor degree.Chronic nephritis, particularly if associated witharterio-sclerosis or alcoholism, may cause or beassociated with Zucker-gussleber, and pearly spotson the pericardium ; but the fibrosis never approxi-mates to that met with in polyserositis.

Polyserositis appears to be distinct from " adherentpericarditis " of rheumatic, tuberculous, or pyogenicorigin. Its association with chronic nephritis or

alcoholism may be fortuitous or causative, the

aetiology of both being unknown. In the case

described this association was absent.Polyserositis is an essentially chronic disorder

of the middle and later periods of life, whereas peri-carditis is usually seen in young people. Thesymptoms are insidious-namely: (1) Abdominal

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pain, due to involvement of peritoneum. (2) Recurrenteffusions into serous cavities, requiring more frequenttapping than those of simple cirrhosis of the liveror less virulent forms of pleurisy. (3) Obstructionof the great veins of the trunk with oedema of thelimbs. Despite these symptoms the patient’s condition may remain good for as long as five or ten years.(4) There is also apparent glandular enlargement inaxillse and groins, due to embedding of lymphaticnodes in active fibrosis of connective tissue.

Radiography may help in deciding that the heartis fixed, the normal movement being replaced byan up-and-down motion; the cardiac enlargementdistinctive of pericarditis may be absent in poly-serositis. The electrocardiogram may show fixationof axis, due to partial or complete immobilisation ofthe heart.The fluid obtained from the pleural cavities is

usually clear, yellow, cell-free, and sterile, andcontains 3 per cent. of albumin ; the ascitic fluidhas occasionally been described as chylous.The fibrosis may be greater on the right side of the

body, possibly because there are more lymphaticchannels through the right cupola of the diaphragmthan through the left. Death results from slowconstriction of lungs, heart, and great vessels.

CASE-HISTORY

In 1929 a man, aged 38, sustained an " injury " to thesacro.iliac region while at work. There were no radiographicsigns, but he was thenceforward unable to work and wasgiven weekly compensation. In November, 1933, he was inhospital with pain in back; " loss of use " and swellingof legs; cough, six months; sense of constriction inthroat. He discharged himself after three days, but inDecember, 1933, was admitted to another hospital.Complaint: pain right chest and pit of stomach,

especially after food ; dyspncea ; swelling of legs ; cough.Physical state : cyanosis ; distended chest veins;

solid middle and lower lobes right lung; right clear. pleural effusion ; fixed, firm glands in axillae and femoral

triangles ; much frothy sputum ; heart displaced to left ;pulse-rate 120 ; afebrile ; ascites absent ; tender liver ;Wassermann reaction negative ; no ansemia ; 13,600 totalleucocytes per c.mm., 11,600 (84 per cent.) being neutro-phils ; X ray ? neoplasm right lung.

Diagnosis : neoplasm right lung.After discharge the right pleura was tapped every two

or three weeks. Accidental pneumothorax occurred onceand appeared to give relief and postpone the next tapping.

FIG. 1. Fibrosis encroaching on inguinal gland. Verycellular, vascular, and of active growth. (x 100.)

FIG 2.-Pleura. Features similar to Fig. 1. (x 100.)

FIG. 3.-Subpleural fatty connective tissue ; vascularised andpermeated by lymphoid and plasma cells. (x 200.)

FIG. 4.-Hepatic peritoneum. Portion of acute inflammatoryfocus ; polynuclear leucocytes numerous. (x 200.) .

There was increase of hepatic pain and tenderness, withoedema of adjacent anterior abdominal wall; more

frequent acute epigastric pain and vomiting, only relievedby morphia, and slight ascites. In October, 1934, he wasreadmitted to hospital. There was loss of weight;tense abdomen, with slight ascites ; slight pleural effusionand pneumothorax; 70 per cent. haemoglobin, 9200

neutrophils per c.mm. ; liver enlarged downwards andtender ; signs of cardiac hypertrophy and dilatation absent.An inguinal gland was excised for examination. Thepatient discharged himself after one week, and inNovember, 1934, at the age of 43, he died by suddenfailure of right side of heart.

NECROPSY

(?ee.—Pale ; ; moderate wasting ; upper abdomen

prominent and tense ; chest assymetrical, left side moreprominent anteriorly than right; varicose distensionof superficial veins of neck and upper half of chest ; diffuseswellings, apparently glandular, in both groins and bothaxillse.Thorax.-Back of sternum only detached from peri.

cardium and mediastinum by cutting dense, white, ratherelastic tissue, which spreads laterally over anterior bordersand surfaces of both lungs. Large, slightly hsemorrhagicpleural effusions (bilateral). Left lung compressed bypleural effusion ; substance oedematous and congested ;lung free except on medial aspect, where the pleura fuseswith general mediastinal mass of dense, white tissue ;lateral and posterior left pleura normal. Right pleuralsac partly obliterated by loculi of yellow, gelatinousexudate ; right lung much collapsed, encased in densecoat of " sugar ice," with pitted surface, and 2 to 7 mm.thick; upper lobe removed by incision through largeareas of fusion of visceral and parietal pleura; rightparietal pleura, where free, is 5 to 8 mm. thick; thissclerosis penetrates upper intercostal spaces on bothsides, infiltrates the axillary spaces and embeds groups oflymphatic glands of normal appearance ; sclerosis lacksdefined limits and resembles mediastinal tissue. Anterior

part of pericardium thick and adherent to back of sternumand anterior surface of heart. Heart distorted by antero-posterior compression, showing atrophy of muscle andmarked dilatation of right side.

.LMoMMtt.—White, dense sclerosis covers both surfacesof both sides of the diaphragm, upper surface of liver, leftperirenal tissue, and whole of prevertebral tissue, so thata solid mass embeds aorta, inferior vena cava, duodenum,and pelvic portions of ileum and colon. In front of thespine this mass is 20 to 30 mm. thick. Lower border ofliver is at level of umbilicus ; left lobe adherent to anterior

364

abdominal wall; liver weighs 1.9 kg. (plus 20 per cent.).Spleen adherent to stomach and diaphragm. Sclerosisinvolves both iliac sets of main vessels, penetrates to thefemoral triangles where lymphatic glands are embedded,as in axillae. Lateral peritoneum of the pelvis is very thick,burying the nerve-roots to the lower limbs. Skull and

spinal column, central nervous system, and remainingviscera normal.

Microscopical.-Rather than hyaline lamination, thefeatures of the fibrosis are cellularity, vascularity, andactive growth, suggesting active infection, though micro-organisms could not be demonstrated in sections. Thepenetration of the fibrosis to the axillary and inguinalspaces appears unrecorded in the literature.

Polyserositis should be considered, therefore, inthe presence of any or all of the following symptoms :mediastinal or abdominal venous obstruction,recurrent effusion into serous cavities, adherent

pericardium, and enlargement of the liver-even ifthese are associated with apparent glandular enlarge-ment. In the case described. the pericardial lesionwas an embedding of the heart and great vesselsrather than adhesion between the parietal andvisceral pericardium. Thus it follows that poly-serositis should be considered as an alternative

diagnosis to mediastinal neoplasm, Hodgkin’s disease,adherent pericarditis, and cirrhosis of the liver.

We wish to thank Dr. A. E. Rayner for his permissionto record this case which was under his charge, andMr. H. C. Taylor for the photomicrographs.

BIBLIOGRAPHY

Becke, C. S., and Cushing, E. H.: Jour. Amer.Med.Assoc., 1934,cii., 1543.

Becke and Moore, R. L. : Arch. of Surg., 1926, xi., 550.Boyd, W. : Pathology of Internal Diseases, London, 1931.Edelston, B. : Brit. Med. Jour., 1928, ii., 570.Kelly, A. O. J. : Amer. Jour. Med. Sci., 1903, cxxv., 116.Rolleston, H., and McNee, J. W. : Diseases of the Liver, Gall-

bladder, and Bile-ducts, Edinburgh, 1912.Rothstein, Jacob L. : Arch. of Pediat., 1934, li., 219 and 288.Tidy, H. Letheby : Synopsis of Medicine, London, 1930.White, P. D. : Heart Disease, London, 1931, p. 516.

HISTAMINE IONISATION

IN RHEUMATISM AND ALLIED CONDITIONS

ANALYSIS OF ONE HUNDRED CASES

BY F. SEVERNE MACKENNA, M.B. Dub.HON. PHYSICIAN TO THE ROYAL BRINE BATHS CLINIC AND

PHYSICIAN TO THE HIGHFIELD HOSPITAL FOR

RHEUMATISM, DROITWICH

ALTHOUGH the series of consecutive cases reviewedhere is somewhat short, an analysis of the resultsmay be of value in showing how histamine can

be used in the routine treatment of rheumatism.The total number of applications was 2496-an

average of 25 per patient-and it was usually foundthat at least 12 were required for any permanentimprovement. Apart from an insignificant numberwho were found to be constitutionally unsuited forbalneological treatment, all the patients receivedconcurrently some form of brine bath, and often

massage in addition.The method of treatment employed is essentially

the same as that already described,! with the notableaddition of a preliminary preparation of the area

with multiple punctures and scratches produced bya special scarifier. This procedure is based on thatrecommended by Vats and is now finally consideredbeneficial. In most cases the histamine was givendaily and it is considered important that baths or

1 Mackenna, F. S. : THE LANCET, 1934, i., 1228.2 Vas, S. : Deut. med. Woch., 1932, lviii., 1009.

other additional treatment should follow and not

precede its administration.In the accompanying Table the various groups

have not been subdivided and the nomenclature isbased on the recommendations of the ArthritisCommittee.

Clinical Analysis

In this Table only the disabled parts that receivedtreatment are considered : where there was a mixedcondition the remaining disabilities are ignored.

NON-ARTICULAR CONDITIONS

Fibrositis.-The majority in this group had lumbarand shoulder-girdle fibrositis. Of the 47 cases,7 were passed as clinically cured ; all except oneshowed very great or great improvement, and inmost of them it was believed that sufficient treatmentwould have completely removed the disability. The

greater number had massage in addition to baths.The two cases which are reported as worse were

complicated by an erratic " psyche " which pre-cluded the possibility of relief from any ailment, andtreatment was not persevered with.

.ye’s.—In this group are included cases of rootand trunk sciatica, and brachial neuralgia. Of the10 patients treated, 7 were discharged and haveremained free from pain. Improvement was unsteadyin all and there were occasional recrudescences, eachless severe than the one before. One fell short of

complete recovery because the patient persisted intaking forbidden exercise.

CHRONIC JOINT CHANGES

Osteo-arthritis.-Of the 13 cases, 9 showed improve-ment ; 6 of these were of the hip, 2 of the knee,and 1 of the shoulder-joint. There was a steadylessening of pain and usually an increase of move-ment after the first application. Of 4 patients thatreturned only 1 had become worse in the interval(seven months). In 4 the improvement lasted onlya few hours.Rheumatoid Arthritis.-Only 3 patients were treated,

and of these 1 alone showed definite improvement.Villous Arthritis.-The knee was affected in each

of the 23 cases, and there was almost always a

very gratifying result, with loss of pain and greatlyincreased movement. Massage was given in everycase. In this group again 1 patient failed to respondor persevere.

Spondylitis.-The 2 cases treated were both of theosteo-arthritic type, the patients being men of 35and 38. There was much improvement in posture,with a great lessening of pain, and this progress hadcontinued in one of the patients who returned after3t months for a second course. Plaster shells werefitted for night use, and baths and massage werealso given.

TRAUMATIC CONDITIONS

Both the patients in this group had " badmintonelbow " and recovered rapidly and uneventfully with