Vol. 60, 1909 - University of North Carolina at Chapel Hill

192 THE CHARLOTTE MEDICAL JOURNAL.
posure, but it might in rare instances be rayed areas. In practice the dosage works
due to some idiosyncrasy on the part of the out so nicely that every part receives an
patient in the same way as the occurrence equal amount and depilation is total and
of alopecia areata after ringworm. He has complete, without anywhere a sign of over
been unable to obtain any definite evidence or under exposure. In theory, according
of injury to the brain by this method of to the well known laws that the quantity of
treatment from his own cases, from the rays received at any point exposed varies
literature on the subject, or from any one (l) inversely with the square of the distance
with experience of this treatment whom he from the source; and (2) directly with the
has asked. Adamson remarks that depila- size of the angle of incidence, the dose retion
by means of the x-rays is now fully ceived by any part of the scalp is found to
established as the most satisfactory method be with mathemalhical accuracy, one pasof
treatment for ringworm of the scalp, tille dose.
Briefl}', the treatment consists in temporarily
depilating the affected area or areas, A Case ol Tuberculous Meningitis
each by a single measured dose of x-rays, -without Tubercles.— lliggs, in The Edinand
thus, mechanically, and without actu- burgh Medical Journal, reports such a case,
ally killing the fungus, eradicating it from the unusual features of which are: 1. The
the areas exposed. By the introduction of presence of tuberculous meningitis with
the pastille of Sabouraud and Noire as a much fibrinopurulent exudate at the base
means of measurement of dosage, in trained of the brain without any miliary tubercle
hands, the dangers of the treatment have formation: 2, the absence of miliary tuberdisappeared.
One disadvantage it still has, culosis of the lungs and other organs; and
namely, the length of time occupied Ijy the 3, the great predominance of polj^morphoactual
exposures to the rays, and any means nuclear leucocytes over lymphocytes in the
of shortening this period must be welcomed cerebrospinal fluid. The child only lived
by all who have many such cases to treat, two days after admission to the hospital,
more especially in hospital or institution but a diagnosis of tuberculous meningitis
work. In a large majority of cases it is was made from the history and physical
found necessary to irradiate the whole scalp, signs. At the necropsy, however, doubt
By Sabouraud and Noire's well known was thrown on this diagnosis, as, although
method with circular localizers from ten to there was an actively caseating bronchial
twelve exposures are necessary in order to gland to serve as a primary focus, there
x-ray the whole scalp, and reckoning only was no generalized miliary tuberculosis and
fifteen minutes for each exposure and a no tubercles in the meninges, which, morecertain
time for adjusting the localizers for over, showed much thick fibrinopurulent
each area, the time occupied in x-raying exudate, mainly posterior basal in distributhe
whole scalp is from three and a half to tion. On the other hand, the general
four hours. By another method, that of "stickiness" of the meninges and the presdividing
the scalp into rectangular areas ence of some exudate around the vessels in
and irradiating each area, surrounded by a the Sjivian fissures favored the diagnosis
lead foil shield, in succession, the time may of tuberculous meningitis. The doubt as
be reduced to from two and a half to two to the diagnosis was accentuated by the
hours. The author reduces the number of cytological examination of the cerebroexposures
to five, so that it is possible to spinal fluid. With regard to the reason
irradiate the whole scalp in one and one- why tuberculous granulations are not alhalf
hours. Its essential features are that ways found in cases of generalized tuberno
cylindrical nor lead foil localizers are culosis, it may be considered that while
used, but that adjacent x-ray applications general tuberculosis infection usually takes
are made in such a manner that at those the form of a pysemia it may occasionally
parts where overlapping does occur the in- be only a septicemia, ond that the primary
cideuce of the rays is so oblique and so tuberculous focus in the first case dismuch
further from their source that no ex- charges into the circulation clumps of bacessive
dose is given. It is important to cilli with tissue debris, and that these
make the irradiation at right angles to the clumps, becoming impacted in the smallest
direction of the irradiation of adjacent areas, arterioles, cause the formation of miliary
and to aim not at a point in the centre of tuberculous granulations or "tuberculous
the vertex of the lower occiput, or of the pysemic abscesses" around the blocked vessides
of the scalp, but toward the outer sels, but that in the second case separate
margin of these areas, so that half the dose bacilli only are discharged into the circulagoes
on to the scalp and half on to the shield tion in considerable numbers, and that
protecting the face and neck. If these pre- these isolated bacilli do not get lodged in
cautions are taken there is no risk of over the small vessels. The difluse leucocytic
exposure at the overlapping margins of the infiltration of the cerebral cortex and the