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PROCEEDINGS

l&r

OP THE

ROYAL SOCIETY OF MEDICINE

EDITED BY'

Sir JOHN Y. W. MacALISTER

UNDER THE DIRECTION OF

THE EDITORIAL COMMITTEE

VOLUME THE SIXTEENTH

SESSION 1922-23

PART III

SECTIONS:—

OBSTETRICS AND GYNyECOLOGY ODONTOLOGY OPHTHALMOLOGY
ORTHOP.EDICS OTOLOGY PATHOLOGY PSYCHIATRY SURGERY
THERAPEUTICS AND PHARMACOLOGY
TROPICAL DISEASES AND PARASITOLOGY UROLOGY WAR

INDEX

j'bmo

LONDON

LONGMANS, GREEN k CO., PATERNOSTER ROW

19 2 3

London :

John Bale, Sons and Danielsson, Ltd.,
Oxford House,

Great Titchfield Street, Oxford Street, W. 1.

PROCEEDINGS

OF THE

ROYAL SOCIETY OF MEDICINE

EDITED BY

Sir JOHN Y. W. MacALISTER

UNDER THE DIRECTION OF

THE EDITORIAL COMMITTEE

VOLUME THE SIXTEENTH

SESSION 1922-23

SECTION OF OBSTETRICS & GYNAECOLOGY

LONDON

LONGMANS, GREEN & CO., PATERNOSTER ROW

1923

London:

John Balk, Sons and Danielsson, Ltd.,
Oxford House,

Great Titchfield Street, Oxford Street, W. 1.

PROCEEDINGS

OF THE

ROYAL SOCIETY OF MEDICINE

EDITED BY

Sir JOHN Y. W. MacALISTER

UNDER THE DIRECTION OF

THE EDITORIAL COMMITTEE

VOLUME THE SIXTEENTH

SESSION 1922-23

SECTION OF OBSTETRICS & GYNAECOLOGY

LONDON

LONGMANS, GREEN & CO., PATERNOSTER ROW

1923

Section of ©botetrics anb (Btmaecoloap

OFFICERS FOR THE SESSION 1922-23.

President —

T. Watts Eden, M.D.

Past

Sir Francis Champneys, Bt.,

M.D.

Sir J. Halliday Croom, M.D.
Alban Doran, F.R.C.S.

Presidents —

Amand Routh, M.D.

Sir William J. Smyly, M.D.
Herbert R. Spencer, M.D.
Henry Briggs, F.R.C.S.

Vice-Presiden ts —

Lady Barrett, C.B.E., M.l). Cuthbkrt Lockykr, M.D.

Sir George F. Blacker, C.B.E., M.D. Louise McIlroy, O.B.E., M.D.
J. S. Fairbairn, B.M. Amand Routh, M.D.

Arthur E. Giles, M.D. Herbert Williamson, M.B.

Thomas Wilson, M.D.

Hon. Secretaries —

J. P. Hedlky, M.Ch. Eardley L. Holland, F.R.C.S.

Other Members of Council —

J. Bright Banister, M.D.

J. D. Harris, F.R.C.S.

Comyns Berkeley, M.D.

H. Clifford, F.R.C.S.

Trevor B. Davies, M.D.
Malcolm Donaldson, F.R.C.S.
A. J. McNair, M.B.

J. D. Malcolm, F.R.C.S.Ed.

R. Glyn Morgan, M.C.

H. Leith Murray, M.D.

A. C. Palmer, M.B.

Miles H. Phillips, M.B.

A. H. Richardson, F.R.C.S,

D. W. Roy, F.R.C.S.

T. G. Stevens, F.R.C.S.

H. Beckwith Whitehouse, M.S.
J. M. Wyatt, F.R.C.S.

J. Young, D.S.O., M.D.

Representative on Library Committee —
Hugh J. M. Playfair, M.D.

Representative on Editorial Committee —
H. Russell Andrews, M.D.

SECTION OF OBSTETRICS AND

GYNAECOLOGY.

CONTENTS.

June 20, 1922.

Report of a Committee of the Section of Obstetrics and Gynaecology of the
Royal Society of Medicine upon the Prognosis and Treatment of
Eclampsia

PAliK

October 5, 1922.

Arthur E. Giles. M.D., B.Sc., F.R.C.S.Ed.

(.1) Large Fibroid of Cervix developing after Subtotal Hysterectomy ... 12
(2j Indications for and Results of Myomectomy for Uterine Fibroids ... 12

Victor Bonnky, M.S.

The Scope and Technique of Myomectomy (Abstract) ... ... 22

January 4, 1923.

Shown by Eardley Holland, F.R.C.S.

A Specimen of Primary Carcinoma of the Vagina ... ... ... 25

Shown by Thomas G. Stevens, F.R.C.S.

Specimen of Squamous Epithelioma of the Vagina ... ... ... 2l>

Hrrijrrt R. Srenckr, M.I).

A d cnoma of the Vaginal Fornix simulating Cancer of the Cervix ... 27

A. H. Richardson, F.R.C.S.

A Uterus removed for Carcinoma of the Cervix after Treatment by

Radium ... ... ... ... ... ... ... 21

T. \\. Eden, M.I). (President), and Aubrey Goodwin, M.D.

Two ('uses of Cancer of the Cervix treated by Radium before Operation .22
Kobkrt Wise, M.D.

Glycosuria, resulting in the Birth of a Dead Child, treated with success

in a Subsequent Pregnancy ... ... ••• ••• ... 25

Clifford White, F.R.C.S.

Instruments left in the Peritoneal Cavity ; The Effects and Results of
this Accident as shown by an Analysis of Forty-four hitherto Un¬
published Cases ... ... ... ... ... ... 26

»--7 I r\

Contents

February i, 1923.

Shown by J. S. Fairbairn, B.M. page

(1) A Necrotic Fibro-adenoma in a Patient, aged 74, simulating Cancer

of the Corpus Uteri ... ... ... ... ... ... 45

(2) A Cyst of the Uterine Cornu due to Dilatation of the Interstitial

Portion of the Tube ... ... ... ... ... ... 45

BbCKWITH WHITEHOU8K,

Adenomatosis Vagina* ... ... ... ... ... ... 46

W. R. White-Cooper, M.B., B.S.Lond., and H. K. Griffith, F.R.C.S.Eng.

Inversion of the Uterus occurring in the Third Week of the Puerperimn 48

Samuel J. Cameron, M.B.

The Technique of Ctesarean Section ... ... ... ... 50

Beckwith Whitehouse, M.S., F.R.C.S., and Henry Featherstonb, M.B.

A Note on Two Cases of Caesarean Section under Spinal Anaesthesia with

Tropacocaine... ... ... ... ... ... ... 55

March 1, 1923.

Henry Briggs, F.R.C.S.

(1) Angioma of the Vaginal Wall ... ... ... ... ... 61

(2) Section of Curettings ... ... ... ... ... ... 61

Shown by A. C. Palmer, F.R.C.S.

A Mass of Secondary Leiomyosarcoma following Subtotal Hysterectomy 62

Shown by Eardlry Holland, F.R.C.S.

A Leiomyosarcoma of a Fibromyoma removed by Subtotal Hysterectomy 64

Shown by J. D. Barris, F.R.C.S.

Two Specimens of Sarcoma of the Uterus ... ... ... ... 65

Shown by S. Gordon Lukkr, M.I).

Chorion-epithelioma of the Uterus showing a very Extensive Growth in

the Uterine Wall ... ... ... ... ... .. 67

Sidney Forsdike, M.D., F.R.C.S.

The Treatment of Severe and Persistent Uterine Haemorrhage by Radium,

with a Report upon Forty-five Cases ... ... ... ... 69

May 3, 1923*

L. Carnac Rivktt, F.R.C.S.

(1) A Calcified Tumour of the Recto-vaginal Septum ... ... ... 81

(2) A Ruptured iliematoma of the Ovary, with Extensive Intra-peritoneal

Haemorrhage... ... ... ... ... ... ... 81

Archibald Donald. M.D.. Ch.M.

The Clinical Aspects of Adenomyomata of the Female Pelvic Organs ... 82

L. P. Pugh, B.Sc.Lond., F.R.C.V.S.

Graves’ Disease and Thyroid Instability in the Cow, and its Relation to
Ovarian Disease

Contents

June 7, 1923.

Herbert R. Spencer, M.D. page

(1) Sarcoma in an Ovarian Dermoid Tumour ... ... ... 101

(2) Ruptured Unilateral Solid Cancer of Ovary; Ovariotomy; no Recur¬
rence Six Years later ... ... ... ... ... ... 105

(8) Stretching of the Epithelium of the Tubal Rugae by Blood effused

into them in Torsion of Pedicle of Ovarian Tumour ... ... 106

Henry Russell Andrews, M.D.

Carcinoma of a Prolapsed Cervix in a Woman, aged 77 ... ... 109

Leonard Phillips, M.S., M.B., B.Sc.Lond., F.R.C.S.Eng.

The Treatment of Dysmenorrhoea: An Analysis of 100 Cases... .. 110

SECTIONS OF OBSTETRICS AND GYNAECOLOGY,
THERAPEUTICS AND PHARMACOLOGY.

(JOINT MEETING.)

December 7, 1922.

H. H. Dale, C.B.E., M.D., F.R.S. page

The Value of Ergot in Obstetrical and Gynaecological Practice ; with

Special Reference to its Present Position in the British Pharmacopoeia 1

Discussion: Sir Nestor Tirard, Dr. Herbert Spencer, Professor W. E.
Dixon, F.R.S., Dr. T. W. Eden, Mr. Aleck Bourne, Professor H. Briggs,

Dr. Dale (reply), pp. 5-7.

The Society does not hold itself in any way responsible for the statements made or
the views put forward in the various papers.

London :

John Bale, Sons and Danielsson, Ltd.,

Oxford House,

83-91, Great Titchfield Strjet, Oxford Street, W. 1.

Section of ©bstetrice anfc (Bsnrecolocv.

President—Professor Henry Briggs, F.R.C.S.

Report of a Committee of the Section of Obstetrics and
Gynaecology of the Royal Society of Medicine upon the
Prognosis and Treatment of Eclampsia . 1

The Committee was appointed in October, 1921, and consisted of the
following members: Mr. A. W. BOURNE, Dr. T. W. Eden, Mr. EARDLEY
Holland, Professor Louise McIlroy, and Dr. Herbert Williamson.

In order to assist them in the investigation the Committee subsequently
co-opted the following: Mr. GORDON Ley (since deceased), Dr. A. J. McNair,
and Dr. Everard Williams.

The Committee desire to record their indebtedness to the three co-opted
members for their very valuable assistance. The late Mr. Gordon Ley, with
characteristic energy, undertook a large share of the very arduous work of
analysing the returns of the 547 cases which were recorded, and the Committee
would wish to make a special acknowledgment of their indebtedness to him,
and of their deep regret that he did not live to see the completion of the work
in which he had taken such a deep interest.

As the basis for a discussion upon the treatment of eclampsia it is
necessary to obtain as accurate information as possible regarding the methods
which have been adopted in recent years, the severity of the cases to which
these methods have been applied and the results which have followed.

The Committee have therefore undertaken an examination of the whole of
the cases admitted during a period of ten years to the following hospitals:
St. Bartholomew’s, Charing Cross, St. George’s, Guy’s, King’s College, The
London, St. Mary’s, Middlesex, St. Thomas's, University College, Westminster,
Boyal Free, Queen Charlotte’s Lying-in, City of London Maternity, General
Lying-in.

We have included in our analysis those cases only in which convulsions
occurred, and have endeavoured as far as possible to exclude cases of chronic
renal disease complicated by uraemic fits in pregnant and parturient women.

The period selected, from 1911 to 1921, is an unfortunate one in some
respects for it embraces the Great War during which, in many instances, the
case-records were of necessity incomplete, and chemical and other investigations
limited to those which were strictly essential.

A study of the material investigated shows that during the selected period
547 cases of eclampsia were admitted to these hospitals, and of these 427
patients recovered and 120 patients died. The maternal mortality is therefore
22'1 per cent.

Although our primary aim has been to ascertain the results of treatment,
the analysis of the figures we have obtained has thrown light upon some

1922.

Lead at a meeting of the British Congress of Obstetrics and Gynaecology, Liverpool, June 30*

D—Ur I

Report of the Committee on Rclampsia

points in the natural history of the disease, and we have therefore included in
our report such information on these points as appeared to be worth placing
on record.

^Etiological Factors.

Yearly Incidence .—From time to time the opinion has been advanced that
the incidence of eclampsia is subject to wide yearly and seasonal variations.
To test the truth of these opinions we have examined a series of 400 cases.
On analysing these cases we find:—

In 1911
„ 1912
1913
„ 1914
„ 1915
„ 1916
„ 1917
„ 1918
„ 1919
„ 1920

20 cases were admitted to hospital
26
22

*100

The table shows that the largest number of admissions occurred in the
years 1920, 1919, and 1914: the smallest number of admissions in the pre-war
years 1913, 1912 and 1911; and that in the year 1920 the number of admis¬
sions was more than three times the number for 1911.

The figures do not support the view that eclampsia is an epidemic disease,
nor would it be correct to draw the conclusion that eclampsia is on the
increase. The larger number of admissions to hospital in recent years is more
probably due to increased hospital accommodation and a wider recognition of
the danger of the disease, so that there is an increasing tendency to transfer
these patients to hospital rather than to treat them in their own homes.

Seasonal Incidence .—An examination of the same 400 cases shows that:—

In the month of January
„ ,, February

,, ,, March

„ „ April ...

„ ,, May ...

,, ,, June ...

,, ,, July ...

„ „ August

,, ,, September

,, ,, October

,, ,, November

,. ,, December

28 cases were admitted

38
34
26

400

These figures suggest that the incidence of eclampsia is not liable to
seasonal variations: thus, in this particular series the highest number of
admissions took place in March and the lowest number in February: in the
first half of the year 204 cases were admitted and in the second half 196.

Infliumce of Parity. —The necessary information is available in 488 cases.
Of these patients, 341 were primigravidaB and 147 were multiparas; giving a
percentage of primigravidaB, 69'8 per cent.; multiparas, 30'2 per cent.

Proportion of Tiuin Pregnancies. —The necessary information is available
in 508 cases. Single births occurred in 467 (91 per cent.); twin births
occurred in 41 (9 per cent.). If the average frequency of twins be taken as
one in ninety deliveries, these figures indicate that twin pregnancy is much
more liable to be complicated by eclampsia than is single pregnancy.

Section of Obstetrics and Gynaecology

Grouping of Cases.

It is agreed that eclampsia is a disease which varies greatly in severity in
different cases and although it is not possible to establish any fixed standard
by which the severity of a case can be indicated in simple terms, yet it is clear
that if we are to compare the effects of different forms of treatment some such
standard is necessary, for if a particular treatment has been adopted in mild
cases only, and another treatment in severe cases only, it is obvious that the
results obtained in the two groups are in no way comparable. We have there¬
fore endeavoured to ascertain what signs and symptoms are of grave import
and to group the cases according to the presence or absence of these particular
signs and symptoms.

With this object in view we have studied the effects upon prognosis of the
following phenomena: Coma, the pulse-rate, the temperature, the number of
fits, the amount of albumin in the urine, the degree of oedema, the blood-
pressure.

Coma .—Three hundred and eighty-five cases have been analysed. The
analyses were made by different members of the Committee and the results
are not presented in precisely the same form. We have therefore to consider
two series. First , a series of 262 cases in which three groups are distinguished,
viz.: (1) Deep coma; (2) coma; (3) no coma, but drowsiness or restlessness.
Secondly , a series of 123 cases in which two groups only are distinguished, viz.:
(1) Cases with coma; (2) cases without coma.

Series /, 262 Cases.

Degrea of coma Number of cases

Deep coma . 60 (incidence

22*9 per cent.)

Coma .93 (incidence

35'5 per cent.)

No coma ; drowsiness. J 109 (incidence
or restlessness I 41*6 per cent.)

Recovered

Died

Mortality

22 (36*6 per cent.) ..

.. 38 ..

63'4 per cent.

74 (79*5 per cent.) ..

.. 19 ..

20* 1 per cent.

103 (94*5 per cent.) ..

6 .

5*4 per cent.

Series II , 123 Cases .

Group I .—Coma present: 75 cases, 21 deaths, mortality 28 per cent.

Group II .—Coma absent: 48 cases, 2 deaths, mortality 4*1 per cent.

Considering the two groups together we find that the mortality of cases
with coma is 34*2 per cent., and of cases where the coma is described as
“deep” 63*4 per cent., whereas the mortality of cases without coma is
5*09 per cent.

It appears therefore that coma is a grave symptom, and deep coma carries
with it a bad prognosis.

The Pulse-rate .—Three hundred and forty-three cases have been examined
and have been divided into three groups: Group I, where the pulse-rate is
over 120 ; Group II, where the pulse-rate is between 120 and 90 ; Group III,
where the pulse-rate is below 90.

! iroiij*

Number of cases

Died

Mortality

110 (incidence 32’0 per cent. >

40*0 per cent.

l r >9 (incidence 46 3 per cent.)

1 14

9*4 per cent.

III

74 (incidence 21 2 per cent.)

5 1 per cent.

A pulse-rate of over 120 is therefore of grave significance.

Temperature .—The temperature has been examined in 351 cases and the
cases divided into three groups: Group I, temperature above 103 F.; Group

4 Report of the Committee on Eclampsia

II, temperature between 103° and 100° F. ; Group III, temperature below
100° F.

Group Number of ewes

I ... 39 (incidence 11*1 per cent.)

II ... 126 (incidence 35*6 per cent.)

Ill ... 187 (incidence 53*2 per cent.)

Recovered

Died

Mortality

74*3 per cent,

111

11*2 per cent.

. 176

5*9 per cent.

A temperature of over 103° F. is therefore of grave prognostic import.

Number of Fits .—The number of fits is recorded in 426 cases. A more
detailed analysis of these will be made later. It will be sufficient to state
here that the average number amongst those who recovered was 6 8, and
amongst those who died 12'7. A larger number of fits than ten appears to be
a grave sign.

Albuminuria .—The amount of albumin in the urine is recorded in 383
cases. We have divided the cases into four groups : Group I, albumin absent;
Group II, a small amount; Group III, a large amount; Group IV, urine solid

on boiling.

Group

Number of cases

Recovered

Died

Mortality

2 (incidence 0*5 per cent.)

—

38 (incidence 9*9 per cent.)

213 (incidence 55*6 per cent.)

8*0 per cent.

III

... 183

14*0 per cent.

130 (incidence 34 2 per cent.)

25*3 per cent.

A urine which becomes solid on boiling is therefore a sign of grave danger.
CEdema .—The absence of oedema or its degree when present is stated in
303 cases. It is difficult to establish a definite standard, but the cases fell
into three groups: Group I, where a note is made that there was no oedema;
Group II, where the oedema is described as “ slight,” moderate or local; Group
III, where the oedema is described as “ great ” or “universal.”

Group

Number of cases

Recovered

Died

Mortality

51 (incidence 16*8 per cent.)

. 29*4 per cent.

142 (incidence 46*8 per cent.)

... 120

15*4 per cent.

III

110 (incidence 36*3 per cent.)

16*3 per cent.

From these figures it appears that the absence of oedema is of grave
significance, but the presence of widespread oedema is not.

Blood-pressure .—We find systematic records of blood-pressure in a series
of 85 cases only. We have divided the cases in this series into three groups :
Group I, below 140 mm. of mercury ; Group II, between 140 and 200 mm. of
mercury; Group III, above 200 mm. of mercury.

Group

III

Number of cases

Recovered

Died

Mortality

19 (incidence 22*3 per cent.)

21 per cent.

55 (incidence 64*7 per cent.)

20 per cent.

11 (incidence 13 0 per cent.)

36 per cent.

It appears, therefore, that a blood-pressure of above 200 is attended by a
high mortality-rate.

From our study of these isolated symptoms we conclude that the follow¬
ing seven phenomena are signs of danger : Coma, a pulse-rate over 120, a
temperature above 103° F., a number of fits greater than ten, a urine which
becomes solid on boiling, the absence of oedema, a blood-pressure above
200 mm.

When a patient exhibited any two of the above phenomena the case has
been grouped as a “severe” one, when these phenomena were absent, as a
“ mild ” one.

Section of Obstetrics and Gynaecology

Adopting this classification we find :—

Mild cases

264

Severe cases

161

Moribund

439

Insufficient details for classification

106

Total .

647

601 per cent.
36*6 per cent.
3 3 per cent.

Further Study of the Maternal Mortality.

The maternal mortality-rate has been further examined in relation to :—

(1) Parity.

(2) The period of gestation at which the eclamptic convulsions supervened.

(3) The number of fits previous to treatment.

(4) The incidence of fits before, during or after labour.

(5) The sudden onset of convulsions without preceding symptoms.

(6) The persistence of the fits after delivery.

Parity.— The number investigated was 458.

Total Recovered Died

Primigravid® ... 332 ... 269 (79*5 per cent.) ... 62 (20*6 per cent.)

Muitipar®. 126 ... 96 (76*4 per cent.) ... 30 (23 6 per cent.)

The mortality is therefore a little higher amongst multiparse than amongst
primigravidae.

The Period of Gestation at which Eclamptic Convulsions supervened .—The*
number of cases investigated is 413.

Period

Total

Recovered

Died

Mortality

Before '28th week.

46 (incidence
10*8 per cent.)

60 (incidence
14*4 per cent.)

... 34 .

.. 11

244 per cent.

Between 28th and 32nd week ...

... 48 .

20*0 per cent.

Between 32nd and 36th week ...

79 (incidence
19*1 per cent.)

... 61 .

18 ..

22*7 per cent.

Between 36th week and full term

229 (incidence
66‘4 per cent.)

... 188

.. 41 ..

17*9 per cent.

The mortality therefore amongst 184 cases before the thirty-sixth week is.
222 per cent. Amongst 229 cases between the thirty-sixth week and full
term 17 9 per cent. The mean mortality for the whole series of 547 cases is
22*1 per cent.

The Number of Fits previous to Treatment .—The number of cases investi¬
gated is 136: 109 patients who recovered had 513 fits before the commence¬
ment of treatment, an average of four fits each ; 27 patients who died had
200 fits before treatment, an average of seven fits each.

The Incidence of Fits before , during or after Labour. —The number of cases
investigated is 447.

Time

Total

Recovered

Died

Mortality

Before labour

287 (64‘2 per cent.)

... 228

20 5 per cent.

During labour

84 (18*7 per cent.)

16'6 per cent.

After delivery

76 (171 per cent.)

27*6 per cent.

The mortality is therefore greatest when the onset of fits is post-partum
and least when intra-partum.

The Sudden Onset of Fits without Preceding Symptoms. —The number of
cases investigated is 386: It is recorded in 69 cases or 17‘9 per cent, that no
symptoms had been noticed before the fits; 59 of these patients recovered

Report of the Committee on Eclampsia

and 10 died, mortality 14*5 per cent. We attach very little importance to
these figures. Few of the cases had been under skilled observation and the
history depended upon the statements of the patient or her friends. In none
of them is there any record of urinary examinations.

Persistence of Fits after Delivery .—(Cases of post-partum eclampsia are
not included.) The necessary information was available in 413 cases. Of
this number the fits continued after delivery in 118 (incidence 28*5 per cent.)
and ceased in 295. In cases classed as “ mild ” the incidence was about
one-third lower than in those classed as “ severe/’

Of the 118 cases in which fits continued 26 died, 92 recovered, mortality
22*1 per cent.—this is exactly the same as the mean mortality of the whole
series; 84 of the 118 cases were classified as either 44 mild” or “severe”;
of these 36 mild cases had no mortality ; the 48 severe cases had a mortality
of 31 per cent.; the remaining cases were not classified.

Of the 295 cases in which fits ceased after delivery 64 died, 231 recovered,
mortality 21*6 per cent.

From this it appears that fits may be expected to cease after delivery in
about four out of five cases; further, the prognosis in those cases in which fits
continue is not unfavourable since the 44 mild ” cases all recovered and the
“ severe ” cases showed a mortality very slightly higher than the mean
mortality of all 44 severe ” cases.

The Results of Treatment.

In considering the results of treatment it must be recollected (1) that
during a considerable part of the period of the Great War the hospitals were
working under exceptional difficulties—e.g., the honorary staff were over¬
worked and reduced in numbers, the resident staff were unusually inex¬
perienced, and there was a shortage of drugs and appliances. (2) That the
Report deals with the returns from fifteen separate hospitals in London ; the
methods of treatment employed were diverse, and the results very unequal in
different hospitals. The results therefore represent the average over the
whole of 1 ondon, and in this respect they may be expected to compare
unfavourably with the results obtained over the same period at individual
hospitals.

The diversity of methods employed has made analysis of results of
treatment very difficult; it is convenient to consider treatment under the
headings of Obstetric Treatment including the method of delivery, and Medical
Treatment.

In considering treatment we have taken only the cases which could be
definitely classified as mild or severe; a certain small number were moribund
on admission to hospital, and these we have excluded; a considerable number
of records were lacking in the data necessary for classification, and they have
also been excluded. There remain 425 cases, of which 264 were mild, and
161 severe. We attach importance to the classification of cases, because we
believe that it will appear from the figures given below that regard should be
had to the severity of the case in selecting methods of treatment.

The mean mortality of the 425 cases is as follows : Recovered, 356 ; died,
69 ; total, 425 ; mortality, 16*2 per cent.

If the cases are divided into mild and severe the figures are as follows :—
Mild, 264—recovered, 247 ; died, 17 ; mortality, 6*4 per cent. Severe, 161—
recovered, 109; died, 52; mortality, 32*4 per cent.

Section of Obstetrics and Gynaecology

(A) Obstetric Treatment.

The cases fall into the following five groups :—

(I) Natural Delivery —i.e., spontaneous delivery without interference of
any kind. Total 89, of which 11 died; mortality, 12*3 per cent. Mild, 50—
recovered, 47 ; died, 3 ; mortality, 6 per cent. Severe, 39—recovered, 31;
died, 8; mortality, 20*5 per cent.

(II) Induction of Labour , delivery thereafter being spontaneous. Total 83,
of which 8 died; mortality, 9*6 per cent. Mild, 59—recovered, 56; died, 3 ;
mortality, 5*1 per cent. Severe, 24—recovered, 19; died, 5 ; mortality, 20*8
per cent.

(III) Assisted Delivery. —These are mostly cases of low forceps, with a
small number in which version was performed. Total 151, of which 22 died ;
mortality, 14*5 per cent. Mild, 100—recovered, 95 ; died, 5 ; mortality, 5 per
cent. Severe, 51—recovered, 34 ; died, 17 ; mortality, 33*3 per cent.

(IV) Gasarean Section •—Of the total six were vaginal operations, five
recovered and one died. Total 88, of which 21 died ; mortality, 23*8 per cent.
Mild, 51—recovered, 46; died, 5; mortality, 9*8 per cent. Severe, 37—
recovered, 21; died, 16 ; mortality, 43*2 per cent.

(V) Accouchement Foret. —Total 14, of which 7 died; mortality, 50 per
cent. Mild 4—recovered, 3 ; died, 1 ; mortality, 25 per cent. Severe, 10—
recovered, 4; died, 6 ; mortality, 60 per cent.

In order to dissociate as far as possible the influence of the disease from
the method of delivery, as factors in mortality, the results in the mild and
severe cases may be compared. The mean mortality in mild cases is 6*4 per
cent., and in severe cases 32*4 per cent., a ratio of exactly 1 to 5. If the mild
cases delivered by the three simpler methods are compared with the severe
cases delivered by the same methods the mortality-rates are 5*2 per cent, and
26*3 per cent, respectively- i.e., the ratio of 1 to 5 is almost exactly main¬
tained. If we compare iu the same manner the cases delivered by Caesarean
section we find that the mild cases showed a mortality of 9*8 per cent., the
severe cases a mortality of 43*2 per cent., which also corresponds closely to
the mean ratio of 1 to 5. The cases delivered by accouchement forc6 are
excluded, because the results are such as to condemn the use of this method
under any circumstancos. Hence it appears that cases which can be classified
as severe may be expected to show a mortality-rate five times greater than
those classified as mild, no matter what method of delivery is adopted.

It is also clear that the cases in which there was no obstetric interference,
or in which simple methods only were adopted, show a much lower mortality
than those delivered by Caesarean section and accouchement forc6. The
mean mortality of the various methods in order are as follows: Induction,
96 per cent.; natural delivery, 12*3 per cent.: assisted delivery, 14*5 per
cent.; Caesarean section, 23 8 per cent.; accouchement forc6, 50*0 per cent.

If now the results of the different methods as they appear in the mild cases
only are compared with one another we get: Induction, 5*1 per cent.; assisted
delivery, 5*0 per cent.; natural delivery, 6*0 per cent.; Caesarean section, 9*8
per cent.

It appears therefore that in mild cases Caesarean section increases the
maternal risk to the extent of nearly two to one, and that cases delivered by
the three simpler methods have much the better chance.

If now the results in the severe cases are compared we get: Natural

Report of the Committee on Eclampsia

delivery, 20*5 per cent.; induction, 20*8 per cent.; assisted delivery, 33*3 per
■cent.; Ceesarean section, 43*2 per cent.

Here also the cases in which there was a minimum of obstetric inter¬
ference show much the best results.

It must be pointed out that within the limits of the classes “ mild ” and
severe ” there were no doubt gradations of severity, and the graver cases
would perhaps be those in which expeditious delivery was regarded as necessary.
Our perusal 'of the records however •show that this was by no means always
the case.

(B) Medical Treatment .

One or two general observations are called for in regard to the medical
treatment carried out in this series of cases.

In the first place it is clear that medical treatment has seldom been carried
out upon any definite plan. One thing after another has been done without
method, and with such rapidity that in many instances the effects of one
could hardly become apparent before the next had been begun. Secondly, in
addition to being disorderly, medical treatment has also been, generally speak¬
ing, excessive. The patient has been subjected to a multiplicity of drugs, and
to a succession of procedures such as venesection, saline transfusion, hot packs,
and gastric and colonic lavage, which might be expected to reduce a parturient
woman in good health almost to the point of death, and must have done
serious harm to one suffering from a grave toxaemia.

An attempt has been made to glean from the records some information as
to the value of medical treatment as a whole, and also as to the value of
individual methods of treatment. For this purpose the various methods of
medical treatment were grouped in the manner set forth below. The cases
which terminated fatally were first selected for investigation by analysing the
medical treatment adopted in each case. The task of analysing the medical
treatment in the whole series of 547 cases was too formidable to be under¬
taken. In the next place venesection and administration of morphia were
selected as representing individual methods of treatment, and a record made
of all the cases in which these methods had been adopted, both those which
recovered and those which died.

The information required for analysing the nature and extent of the medical
treatment adopted in the fatal cases in this series was available in 71 cases.
For convenience of analysis medical treatment has been divided into the
following groups: (a) Elimination (including purgatives except croton oil,
enemata, gastric and rectal lavage, rectal saline, &c.); ( b ) Venesection; (c)
Intravenous saline; (d) Morphia and other sedatives; (e) Croton oil; (/)
Hot packs ; (g) Veratrone.

In the large majority of cases the treatment adopted ranged over three or
more of the above groups. In only seven instances was simple treatment
falling under one heading only adopted. Elimination only in 1 case, intra¬
venous saline only in 2 cases, morphia only in 3 cases, veratrone only in
1 case. In 15 cases the treatment comprised two groups, elimination and
morphia being the combination most often employed. In 24 cases treatment
comprised three groups, elimination, morphia, and hot packs, or elimination,
morphia and veratrone being the most commonly employed combination. In
23 cases complex and varied treatment comprising four or more groups was
carried out. A few cases were subjected to treatment by elimination, vene¬
section, intravenous saline, morphia, hot packs and veratrone. It is impossible

Section of Obstetrics and Gynaecology

to avoid the conclusion that the majority of the fatal cases were over-treated,
and that in a considerable number the excessive treatment must have been a
contributory factor in bringing about the fatal results.

A further attempt has been made to arrive at an opinion as to the value of
individual methods of treatment; in respect of only two methods were the
cases numerous enough and the data sufficiently proved to warrant con¬
clusions being drawn from them. These methods were venesection and the
administration of morphia with or without other sedatives; cases in which
less than one half a grain of morphia had been given were not included. The
results are as follows:—

Venesection : 143 cases. Mild cases, total 60: Recovered, 53 ; died, 7;
mortality, 11*6 per cent. Severe cases, total 83: Recovered, 44 ; died, 39;
mortality, 47*0 per cent. The mean mortality of the mild cases in the whole
series of 425 cases was 5*4 per cent, (see p. 6), the cases in which venesection
was done showed double this mortality-rate. The mean mortality of the
severe cases in the whole series was 34*3 per cent.; the severe cases treated
by venesection showed a mortality of more than one third greater than this.
So far as these results may be relied upon it therefore appears that venesection
is a method from which little benefit is to be expected, and which may do
harm. In one case 40 oz. of blood were taken by venesection and the patient
died.

Morphia and other Sedatives : 69 cases. Mild cases, total 39 : Recovered,
36 ; died, 3 ; mortality, 7*8 per cent. Severe cases, total 30 : Recovered, 14 ;
died, 16; mortality, 53*3 per cent. These results are no more encouraging
than those of venesection.

It must however be recollected that in the case both of venesection and of
morphia very few of these cases were treated by the above methods only;
many other things were done to the patient as well, the effects of which
cannot be disentangled from those of venesection or of morphia.

The Causes of Death in the Fatal Cases.

The proportion of cases in which a post-mortem examination was made
was very small, and the cause of death specified is the clinical cause in the
majority of cases. The notes are in many instances wanting in any indication
as to the cause of death, and in only 87 of the 120 cases which terminated
fatally was any information available, and that was often of a fragmentary
nature.

Of the 87 cases, in 27 no reliable opinion as to the cause of death can be
expressed: in 36, death was attributed to eclampsia, and in this group are a
fair number of autopsies: in 5 cases death was due to cerebral haemorrhage,
these being all cases in which a post-mortem diagnosis could be made. In 10
cases pulmonary complications such as pneumonia, bronchitis, pulmonary
embolism and oedema of the lungs were the cause of death: the other causes
specified are uraemia (one case), suppression of urine (one case), heart failure,
shock, chloroform poisoning, general peritonitis, and accidental haemorrhage.

In one of the fatal cases, two pints of blood were taken by venesection,
and the patient was delivered by accouchement forc6 ; this case was classified
as “ mild on admission,’* and it seems probable that any chance she had of
recovery was destroyed by the severity of the remedial measures employed.
In two cases there*was post-mortem evidence of acute tracheitis and oedema
of the lungs; in both croton oil had been administered, and it seems probable

Report of the Committee on Eclampsia

that here also the methods of treatment employed were to a great extent
responsible for the fatal result.

If the figures are looked at as a whole, we may take it that deaths attributed
to eclampsia, to cerebral haemorrhage, to uraemia or to suppression of urine are
the direct outcome of the disease. These account for 47 cases out of 60 in
which the cause of death could be determined, i.e., 71*5 per cent. In the
remainder—viz., pulmonary complications, heart failure, shock, chloroform
poisoning, general peritonitis, and accidental haemorrhage, it is, at the least, an
arguable proposition, that by more judicious management of the cases a great
number of these fatalities could have been averted.

The Fietal and Neo-natal Mortalities.

In the following tables three groups of cases are considered :

(1) Fatal deaths , including ante-partum, intra-partum, and post-partum
death of the foetus. Some of these foetuses were born with the cord still
pulsating but respiration was never established.

(2) Neo-natal Deaths .—In this group are included all children who died
whilst the mother was still in hospital.

(3) Survivals .—This group includes all children who left the hospital
alive.

Many of these children were premature, and in considering the foetal
mortality in relation to treatment a distinction has been made between those
born before and those born after the thirty-fourth week of gestation, because
in any case the probability of survival of a child born before the end of thirty-
four weeks’ gestation is small.

Total Mortality.

Examination of 448 cases gives the following figures: Foetal deaths, 156
(34*8 per cent.) ; neo-natal deaths, 50 (11*1 per cent.) ; survivals, 242 (54*0
per cent.). Thus of the children born of these cases of eclampsia rather
more than half left hospital alive.

Relation of F<etal Mortality to Number of Fits.

The number of cases analysed is 298 and the number of children born is
303. Of these 156 children were born alive and the mothers of these children
had between them 726 fits—an average of 4*6 fits for each delivery. 147
children were born dead and the mothers had 1,234 fits—an average of 8*4
fits for each delivery.

Relation of F<etal Mortality to the Time of the Onset of Fits.

Fits occurred before the onset of labour in 177 births: 74 children survived,
103 children died, mortality 58*2 per cent. Amongst these were many pre¬
mature births.

The onset of fits was during labour in 33 cases: 24 children survived,
9 children died, mortality 27*3 per cent.

The onset of fits was after labour in 39 cases : 34 children survived,
5 children died, mortality 13 per cent.

Section of Obstetrics and Gynaecology

The Effects of Methods of Delivery upon Fcetal Mortality.

In looking into this matter we have excluded all cases in which delivery
took place earlier than the thirty-fourth week; before this the chances of
survival of the child are very small.

In 206 cases the necessary data were available and of these 137 survived—
i.e., they left hospital alive, and 69 died (still-births and neo-natal deaths); the
foetal mortality was accordingly 33*5 per cent. A comparison of the different
methods of delivery gives the following results .—

Total

Survived

Died

Mortality

Natural or assisted delivery

29*6 per cent.

Induction

56*1 per cent.

(’ a*sa rea n section

23’0 per cent.

Accouchement force ...

100*0 per cent.

The low fcetal mortality of Caesarean section in comparison with that of
induction is remarkable. It is probably explained by the fact that an induced
labour is nearly always prolonged, and the high fcetal mortality is probably
accounted for by the vulnerability of the child.

If the results in the cases born before the thirty-fourth week are examined
separately, the foetal mortality is 80 per cent.

The fate of the child in eclampsia is necessarily subordinate entirely to the
interests of the mother, and we do not wish to attach undue importance to the
consideration of these figures.

Signed on behalf of the Committee ,

T. W. EDEN, Chairman.

dune 15 , 1922 .

Section of ©botetrico ant> Gynaecology.

President—Dr. T. W. Eden.

Large Fibroid of Cervix developing after Subtotal

Hysterectomy.

By Arthur E. Giles, M.D., B.Sc., F.R.C.S.Ed.

In October, 1915, I saw a patient, aged 39, sent to me by Dr. (now Sir
Bruce) Bruce-Porter. She was known to have had fibroids for four years,
and had lately been suffering from increasing haemorrhages, the menstrual
periods being both too frequent and too free.

On examination, a large group of fibroids was found occupying the pelvis
and rising up into the abdomen. Operation was decided upon, and a subtotal
hysterectomy was done three weeks later. Owing to the presence of a right
ovarian cyst, the appendages of the right side were removed. The left append¬
ages, being matted down under adhesions to the floor of the pelvis, were not
disturbed.

A year later the general health was good, but she complained of sacral pain.
A swelling the size of a billiard ball was found on the left side, and a cyst of
the left ovary was diagnosed.

In October, 1917, the pelvic condition felt the same on palpation, but
as symptoms were not pronounced, I advised against operation. Five years
of very good health followed, and the patient was able to live a very active
and useful life.

In August, 1922, Sir Bruce Bruce-Porter asked me to see her again. She
had been conscious of abdominal swelling and discomfort, and Sir Bruce had
found a hard tumour above the pubes. On examination this hard tumour was
found to be filling up the true pelvis, and rising also into the abdomen.
Diagnosis was difficult. Sir Bruce had suggested a fibroid, but as I had
never known a fibroid arise in the cervical stump after subtotal hysterectomy,
I felt doubtful about this, and feared that the left ovarian cyst had developed
a malignant growth. Early operation was urged, and was carried out shortly
afterwards.

Extensive adhesions between the bowel and the bladder shut out the pelvic
contents from view; after these had been separated, the tumour was reached,
encompassed by adhesions on every side. It was carefully shelled out, and
proved to be a large reniform tumour, attached to the top of the cervical stump
by what would correspond to the hilus of a kidney. The tumour was removed
and the cervical stump dissected out. Convalescence was temporarily com¬
plicated by a collection of blood in the pouch of Douglas, evidently arising
from adhesion sites, and judging by the offensive smell, contaminated by
Bacillus coli. This was evacuated by passing the finger through the divided
upper end of the vagina, and after that recovery was satisfactory. The tumour
was sent to Dr. Eastes' laboratory for examination, and the following report
was received : “ This large growth has the histological structure of fibromyoma,

[October 5, 1922.

Section of Obstetrics and Gynaecology

consisting of interlacing bundles of plain muscle tissue and fibrous tissue. It
is innocent. A section was also cut of the cervix, but this presents no special
pathological features.”

There is no doubt that the development of a fibroid in the cervical stump
after a subtotal hysterectomy is a very rare occurrence, hitherto unknown to
me in an experience of nearly 1,000 hysterectomies for fibroids, the majority
of which were subtotal. Sir Bruce Bruce-Porter tells me that he has met
with another instance of it in another patient, but that and the case now
recorded are the only cases within my knowledge.

Those who advocate total hysterectomy in every case of uterine fibroids
would doubtless claim this occurrence as an argument in favour of their view.
Personally, I prefer the subtotal operation in most cases ; and I should not feel
disposed to alter my practice on account of a possibility that may occur once
in a thousand cases.

DISCUSSION.

Dr. Herbert Spencer said a considerable number of cases of development of
fibroids in the cervical stump after amputation of the uterus had been published. It
was only another instance of the advantage of total hysterectomy, which he had
practised exclusively for the last twenty-two years, and had on many occasions recom¬
mended to the Section. The occurrence of fibroids in the stump was, of course, not so
common as the occurrence of cancer, which was said by some to be “ rare.” Seeing
that one American gynaecologist had collected 276 instances of the occurrence of cancer
in the stump in the practice of American gynaecologists alone, and that William Mayo,
of Rochester, U.S.A., had recently published his opinion that total hysterectomy was the
better operation, he hoped that more Members of the Section would become convinced of
its superiority over the partial operation. After total hysterectomy, leaving the vagina
widely open for drainage prevented those exudates and accumulations of blood which
were met with in Dr. Giles’s case, and were not uncommon after subtotal hysterectomy.
He asked how Dr. Giles treated the vagina.

Dr. Giles (in reply) said that his usual practice in the case of total hysterectomy
was to suture the top of the vagina at the sides leaving the middle open for drainage.

Indications for and Results of Myomectomy for Uterine

Fibroids.

By Arthur E. Giles, M.D., B.Sc.

In recent discussions on the treatment of uterine fibroids, the alternatives
of hysterectomy on the one hand and X-ray and radium treatment on the
other have generally been dealt with as though they exhausted the possibilities
of treatment. Myomectomy has been almost entirely overlooked. At the
meeting of this Section in March, 1922, a paper was read by Dr. Fletcher
Shaw, of Manchester, on the X-ray treatment of fibroids, as a sequel to a
former paper by Dr. Eden and Mr. Provis. 1 I then felt that the case for
myomectomy might well be presented, and this contribution is the result.

I hold the view that in the majority of cases of fibroids requiring surgical
treatment hysterectomy is the more suitable and also the more satisfactory
operation, and that the scope of myomectomy is restricted to the minority
of cases. Hysterectomy requires no justification: it is generally accepted

1 Proceedings , 1922, xv (Sect. Obst. and Gyn.)., pp. 51-56.

Giles: Myomectomy for Uterine Fibroids

as a sound procedure, surgically and clinically. But myomectomy needs
to justify itself by its results, and to state reasons why it should be pre¬
ferred ; it must also acknowledge its limitations and define the conditions of
its suitability.

The outstanding claims for myomectomy are first that the uterus is
preserved for the important function of childbearing ; and secondly that the
patient is thereby spared the mental distress of feeling that an essential part
of her womanhood has gone.

The broad-minded advocate of myomectomy will, I think, at once concede
that in a woman who is past the child-bearing age the first claim disappears,
and the second has only an academic existence; although, as I shall
point out, there may be reasons for preserving the uterus that are not founded
on its child-bearing function. But we may properly narrow the issue to
the consideration of myomectomy versus hysterectomy in the child-bearing
period.

The advocate of myomectomy is then, I think, called upon to show in the
first place that the preserved uterus is, in fact as well as in theory, capable of
child-bearing ; and in the second place, that there is a reasonable prospect of
a cure, both anatomically and symptomatically; in other words, that in a large
majority of cases there will be no return of fibroids, and that the patient will
menstruate normally.

The case for myomectomy will best be presented if we begin by examining
the question whether it is justified by its results; and if the answer proves to
be in the affirmative, we can then consider the scope and limitations of the
operation.

A separate short section will be devoted to the interesting subject of
myomectomy during pregnancy.

Results of Myomectomy.

We may glance first at the immediate results, namely, the mortality, as
compared with hysterectomy ; for this purpose my own statistics will serve
as well as any. The figures up to date are as follows : hysterectomy, for
fibroids, 987 cases, seventeen deaths, mortality 172 per cent. ; myomectomy,
167 cases, three deaths, mortality 1*8 per cent.

The above figures represent all cases from 1897. The present-day
mortality is lower, and the figures from the end of 1910 to date are as
follows: Hysterectomy, 684 cases, five deaths, mortality 0’73 per cent.
Myomectomy, 107 cases, one death, mortality 0*93 per cent.

There is thus very little difference in the mortality of the two operations ;
certainly not enough to make this a deciding factor in the choice of
operation.

Later Results.

In my work on the “ After-results of Abdominal Operations,” published in
1910,1 was able to give particulars of forty cases traced out of fifty-one operated
upon. Of the later 116 cases, I have .particulars of fifty-three. I did not
attempt to trace the histories of patients who were over 45 years of age at the
time of operation.

I will take in order the three questions investigated in the previous
cases :—

(7) What is the Likelihood of a Recurrence of Fibroids ?—In the first series,
of thirty-nine cases examined, the uterus was found to be of normal size, with
no return of fibroids, in thirty-five cases, or 90 per cent.

Section of Obstetrics and Gynaecology

In the present series, of forty-nine cases examined, or reported upon by
their doctors, the uterus was normal in size without fibroids in forty-one cases ;
it was enlarged, without fibroids, in three cases ; in all, forty-four cases without
fibroids, or 90 per cent., as in the first series. In five cases fibroids were
observed; the notes about them are the following :—

(1) -Fibroid in fundus : hysterectomy advised on account of bleeding.

(2) Fibroid, size of pea on posterior wall.

(3) Tftultiple fibroids, hysterectomy done nine years after myomectomy.

(4) Fibroid, size of mulberry on anterior wall.

(5) Fibroid, size of pea on anterior wall.

The conclusion is that the liability to return of fibroids may be represented
as 10 per cent.

l(II) How is the Menstrual Loss affected ? —In the first series, the menopause
had occurred before the operation in three cases, and in one case there was no
further loss after operation. Of the remaining thirty-six cases, menstruation
was normal or moderate in thirty-one, or 84*5 per cent.; and free or profuse
in five, or 15 5 per cent. In the present series we can exclude six cases in
which the menopause preceded or synchronized with the operation. Of the
remaining forty-seven cases menstruation was normal and moderate in
thirty-six, or 75*1 per cent.: and in eleven cases it was profuse, either at first,
or later on; or there was intermenstrual loss. Taking all the cases together,
we find that of eighty-three cases, menstruation was normal in sixty-seven, or
80*7 per cent. The conclusion is that there is a liability to menorrhagia
or metrorrhagia after myomectomy in about 20 per cent, of cases. This result
is not altogether surprising; because it is clear that unless we open the uterine
cavity every time we do a myomectomy, some small intra-uterine growth may
easily be overlooked. In order to show that sufficient time had elapsed to
enable one to judge of results, I may mention that the time between the
operation and the report on the cases in the present series was as follows:—

1 to 2 years

2 to 3* ,,

3 to 4 „

1 to 5 „

5 to 6 ,,

6 to 7 „

4 cases

7 to 8 yearn ...

... 2 cast

8 „

8 to 9 .

... 6 „

2 „

9 to 10.

... 7 „

fi „ .

10 to 11.

... 3 ,,

1 „

13 years

... 1 „

12 „

(III) Is the Uterus serviceable for Child-bearing after Myomectemy ?—In
the first series, there were fifteen married women under 45 years of age:
of these, one was four months pregnant at the time of operation, went to term,
and became pregnant again; two others became pregnant after the operation.
In the present series I have after-histories of thirty-seven married women
aged under 45, including two who were single at the time and were married
afterwards. I have drawn up a table of these cases (see Table I, p. 16). One, who
was pregnant at the time of operation, died of eclampsia at her confinement;
and two did not live again with their husbands after operation. Of the
remaining thirty-four, ten became pregnant after the operation, including
two patients who were pregnant at the time, went to term, and became
pregnant again. One patient had two children, and another had four. In all,
therefore, of forty-nine who had the chance of conceiving after operation,
thirteen became pregnant, or 26 per cent.

Now the question that we have to decide is this : are the results of
myomectomy good enough to justify us in practising this operation in suitable
cases? My answer is an unqualified “ Yes,” on the ground that the advantages
far outweigh the disadvantages.

Giles: Myomectomy for Uterine Fibroids

The advantages are represented by the occurrence of pregnancy in 25 per
cent, of the women who had a chance of pregnancy, and by the satisfaction
which patients derived from the consciousness that they remained after the
operation “ like other women. 11 This satisfaction cannot be expressed in
statistics, but it is nevertheless a very concrete advantage.

Table I.— Results of Myomectomy in Relation to Pregnancy.

Number
in present
series

■

Age

Date of operation

Pregnancies after operation

November 11, 1909

None ; husband has been in an asylum all the time

(single)

June 12,1911

Married since; confinement, October 1921

March 14,1912

None

April 15, 1912

Pregnancy at operation ; went to term ; none since

June 30, 1912

None

January 14,1913

None

January 30, 1913

None

j (single)

February 3, 1918

Married in 1914 ; confinements—April, 1916, and March.
1919

March 17, 1913

Pregnancy at operation ; went to term ; none since

! 41

September 25, 1913

None

j 31

October 6, 1913

Confinements—January, 1915, April, 1917, March, 1919,
August, 1922; before operation had been married six
years, without children

November 29, 1913

None

April 24, 1914
June 8, 1914

None ; died in May, 1918

Confinement—October, 1917 ; none since

July 9,1914

None

46 1

October 14,1914

Pregnancy at operation ; went to seven and half months ;
none since

October 22,1914

None

49 1

i 30

November 6,1914

Confinement since, date unknown

December 2,1914

Confinement, June, 1916

58 J

1 34

October 7,1915

Pregnancy at operation ; went to term; another confine¬
ment, May, 1920

October 11,1915

Pregnancy at operation ; went to term ; another confine¬
ment, January,1919

November 11, 1915

None

January 3, 1916

None

April 17, 1916

Pregnancy at operation ; went to term; none since

6*4

May 1, 1916

None ; has not lived with her husband since operation

October 9, 1916

Pregnancy at operation; went to term ; patient died of
eclampsia

January 11, 1917

None ; premature menopause, April, 1921

.35

January 22. 1917

Confinement, February, 1918

November 26, 1917

None

February 6, 1918

None

December 30,1918

Pregnancy at operation ; went to term ; none since

November 25, 1919

Pregnancy at operation ; went to term ; none since

February 5, 1920

Pregnancy at operation ; went to term ; none since

March 18, 1920

None

100

April 14, 1920

None

105

July 20, 1920

Confinement, February, 1922

106

July 21, 1920

None

The disadvantages are the possibility of the return of fibroids which is
a 10 per cent, chance; and the possibility of further menstrual trouble, which
is a 20 per cent, chance. Some women, doubtless, would prefer the assurance
given by hysterectomy, that there will be no return of their troubles, and that
the operation is therefore final. But I am persuaded that the great majority
of women would prefer to take the risk which the figures indicate, for the
possible chance of having a baby. The risk of a second operation being

Section of Obstetrics and Gynaecology

necessary is not as great as 10 per cent.; hysterectomy had been required in
only five cases out of the total 167, that is, in just 3 percent.

I submit therefore that, judged by the criterion of results, the advantages of
myomectomy definitely outweigh its disadvantages in the surgical treatment
of uterine fibroids, in a restricted class of cases. My own sense of this
restriction is sufficiently expressed in the fact that of 1154 cases of uterine
fibroids treated surgically hysterectomy was done in 987, or 85*5 per cent.
The proportion of myomectomy to hysterectomy was thus 1 to 6.

We may now examine the scope and limitations of myomectomy.

Indications for Myomectomy.

There is one important indication for myomectomy and there are several
subsidiary ones. I will take the important one first:—

(1) The Fact that the Patient is of Child-bearing Age .—The younger the
patient, the greater should be the effort to save the uterus, and I should
say that, broadly speaking, myomectomy is the operation of choice in women
up to the age of 40. In single women, the indication is not so great as it is in
married women, especially after the age of 30; because after this age the
expectation of child-bearing is necessarily less in the spinster from the fact
that she has first to get married. The generalization of age in the case of
married women may well be qualified by the question of previous pregnancies :
when a woman has half-a-dozen living and healthy children we need not be so
concerned to save the uterus as we should be in the case of a woman who has
had no children and is ardently desirous of having one. This reflection is well
illustrated in a case of myomectomy during pregnancy, to which I shall refer
later. The influence of age and of the married state upon my own practice is
set forth in the table given (Table II, p. 20) which shows the proportion of
myomectomies to hysterectomies at different ages, in single women, in married
women, and in the two groups taken together. In five-yearly periods the
percentage of myomectomies, which stands at 56*6 for all cases under 30 in
married women, progressively falls to 40*1, 26*7, 6*1 and 5*5 and rises a little
to 10*0 in the case of women over 50. In single women, the percentage is 45*0
for all cases under 30, and falls to 21*3,8*3,8*6, and 4*0, and rises to 10*0 in those
over 50. Taking all the cases together, the percentage is 52*0 in women under 30,
and in successive five-yearly periods it is 34*3, 19*2, 6*9, and 5*1; and for
women over 50, 10*0. It will be noticed that the proportion of myomectomy
is distinctly higher in married women than in spinsters up to the age of 40;
after that age there is not much difference. The chart herewith (p. 18)
illustrates these figures in graphic form.

(2) Association of Uterine Fibroids with Prolapse and Procidentia .—The
rise in percentage of myomectomies after the age of 50 is explained by the fact
that a number of these patients had prolapse or procidentia. In the presence
of this complication I consider it very important to preserve the uterus;
because this can be fixed up to the abdominal wall when myomectomy has
been done, and thus play an essential part in the cure of the displacement.
When the uterus is removed in conditions of procidentia there is a marked
tendency to prolapse of the vaginal walls, which is apt to be very troublesome,
and in severe cases to defy even extensive plastic operations on the vaginal
walls and perineum.

(3) A Deep-rooted Objection on the Patient's Part to Hysterectomy .—In my
experience, the great majority of women suffer no more than a passing regret
for the loss of the uterus, especially when it is explained to them that the

Giles: Myomectomy for Uterine Fibroids

presence of the tumours has rendered it incapable of serving its one function,
that of child-bearing; that the uterus is not the essential organ of sex, and
that its removal has no effect on the specially feminine characteristics and does
not render a woman any the less able to live a married life. But there are
a few women, swayed more by sentiment than by reason, to whom the loss of
the womb seems a greater calamity than the loss of life itself: to them this
organ appears to be the focus and essence of their personality as women,
and if hysterectomy be done, it is apt to be followed by a profound and lasting
depression'which approaches the border-line of mental instability. In dealing

& Ctuwt

Ku, oj- ai^onttctomab

J’lkroids at aja Uwi). ftlcwuul hfomtn only ,

vnltViufitbil turns . urtrrtv€*t avJLj , d oOi A , twu/ •

with a patient of this kind, it is clear that a special effort should be made to
save the uterus, even if the age of child-bearing be past, and myomectomy
entails a rather higher operative risk and the possibility of a return of fibroids.
But in such circumstances the surgeon may feel disposed to advise the adoption
of X-ray treatment, rather than to undertake what seems to him to be an
undesirable surgical procedure.

(4) Certain Characters of the Tumours .—When a tumour is solitary and
pedunculated, and not associated with excessive bleeding, a myomectomy may
properly be done, whatever may be the age of the patient, and the chances of

Section of Obstetrics and Gynaecology

pregnancy. Even an interstitial tumour, unassociated with haemorrhage, may
be enucleated. In fact, when none of the previously considered factors have
to be considered, the deciding question will probably be: “ What is the simplest
and safest operation*? ” ;

The Limitations of Myomectomy.

We have so far considered conditions in which myomectomy should be
done unless there is some strong reason to the contrary. We have now
to enumerate those in which myomectomy should not be done unless there is
some preponderating reason for it :—

(1) The Age Factor .—After the age of 40 or 45,1 consider that hysterectomy
should be the rule, especially when there are multiple fibroids and when there
has been excessive haemorrhage.

(2) The Condition of the Uterine Appendages. —When fibroids are associated
with double tubal disease or with bilateral ovarian tumours, hysterectomy is
the proper procedure.

(3) Size and Position of the Tumours. —Whatever be the position or number
of the tumours, if myomectomy is going to leave a battered and useless organ,
hysterectomy should he done. Cervix-fibroids almost invariably call for
hysterectomy, though I have occasionally done a myomectomy even in these
cases. A fibroid in the broad ligament may, if enucleated, leave the uterine
vessels in a highly vulnerable condition : my first myomectomy was of this
kind, and I had to re-open on account of haemorrhage. The mere number of
the tumours does not greatly matter, as long as a good and serviceable uterus
is left.

(4) Excessive Haemorrhage. —When a patient has had great losses and is
seriously drained thereby, hysterectomy should be the rule. If urgent reasons
call for an attempt at myomectomy, the uterine cavity must be opened, and
any submucous or intra-uterine growth must be removed. Otherwise haemor¬
rhage will continue, and the operation will have been done in vain.

(5) The Tempemmmt of the Patient. —Just as there are a few women whose
temperament renders it important to save the uterus, so there are others
whose temperament will turn the scale in favour of hysterectomy. They are
the patients to whom an operation is such an ordeal that whilst they will face
it bravely if they have the assurance that it is going to mean a definite cure,
they could not tolerate the prospect that the ultimate result of the operation
might be doubtful. With them even considerations of possible future
pregnancy and of preservation of femininity have no weight compared with
the all-important need for being completely and finally cured. With such
a patient, if there be any doubt at all as to the issue of a myomectomy,
hysterectomy should be done.

Myomectomy during Pregnancy.

Fibroids associated with pregnancy do not necessarily call for surgical
treatment. When they are causing no symptoms, and do not seem likely to
interfere with labour, it is best to leave them alone, always provided that the
Patient can be kept under observation so that operation can be undertaken
if urgent symptoms arise, and that the medical attendant is on the look-out for
trouble during labour. After the confinement, the fibroids can be dealt with
°n their merits. Surgical treatment may take the form either of myomectomy
during pregnancy, or of Caesarean section combined with myomectomy or
hysterectomy at term. In exceptional cases, hysterectomy in the early

Giles: Myomectomy for Uterine Fibroids

months of pregnancy may be required, but it should only be done if symptoms
are urgent and there are cogent reasons against the adoption of conservative
procedures.

Myomectomy during pregnancy is indicated in three groups of conditions.
First, when the tumour or tumours appear to be increasing rapidly in size ;
secondly, when the patient is suffering from pain, pressure symptoms or
indications of septic or degenerative changes in the tumours ; thirdly, when
the position of the fibroids makes it probable that labour will be obstructed, in
which case myomectomy is done for the purpose of avoiding the necessity for
Csesarean section and of allowing the confinement to take place naturally.

In the second group, severe and persistent pain is of course a sufficient
indication in itself. The effects of pressure may be exerted in relation to the
bowel, the bladder, the diaphragm, the iliac vessels, or the nerves of the sacral
plexus; and any one of these may call for interference. With regard to
degenerative changes, it is well known that when fibroids are associated with

Table II.—Showing the Proportion of Myomectomies to Hysterectomies at

Different Ages.

Operation

30 and under

31-35

>-40 1

41-45

46-50

er 50

Total

No. i

Per

cent.

No.

Per

cent.

No.

Per

cent.

No. j

Pei

cent.

No.

Per

cent.

No.

Per
cent. .

No.

Pe.

cent.

Married women-

Myomectomy .,

17 |

56*6

40*1

26*7

13 1

5*5

11 1

10*0

125

16*0

Hysterectomy .,

..; 18 |

434

,58

59*9

103

73*3

201

93*9

190 ,

94*5

99 ,

90*0

659

84*0

Total

.. 30 1

100*0

139

100*0

214 |

100*0

201

100*0

110

i i

loo-o |

| 784 f

100*0

Single women —

! i

Myomectomy .

•• 9 ,

450

21*3

8-8

8*6

! 3

4*0

10*0

! 41 i

11*4

Hysterectomy.

• 11

550

78*7

1 78

917

91*4

96*0

90*0

319 |

88*6

Total

.. 20 1

100*0

i 47

1 100*0

j 85

100 0 93

100*0

I 1000

| -to i

1000

360 !

100*0

All cases —

I ;

Myomectomy .

.. 26 j

| 52‘0

1 34*3

19*2

6*9

5*1

10*0

i 166

14*5

Hysterectomy.

.. 24

480

| 65'7

181

80*8

286

93*1

262

94*9

135

900

j 978

85*5

Total

.. 50

100*0

137

100*0

224

j 100*0

307

100*0

276

100*0

I 150

100*0

1144

100*0

pregnancy they are specially liable to undergo that form of necrobiosis known
as red degeneration ” ; and that the onset of this process is frequently marked
by pain so acute and severe as to simulate the torsion of the pedicle of an
ovarian tumour. In one of my cases operation was undertaken under the
impression that the patient had an ovarian cyst with a twisted pedicle.
In the other cases myomectomy was the intended operation.

In all, I have had thirteen cases of myomectomy during pregnancy, the
details of which are of sufficient interest to be recorded in a tabular state¬
ment (see Table III). The period of gestation ranged from a few days to six
months. In the case of “ a few days,” the fact of pregnancy was not known
at the time ; the tumour was a large subperitoneal tumour, and the first
intimation I had of the pregnancy was two months after the operation, when
the patient presented the signs and symptoms of a two months’ pregnancy, and
stated that coitus had taken place two or three days before the operation, and
not since. In Case 11, the patient, aged 36, had been married ten years, and

Section of Obstetrics and Gynaecology

this was her first pregnancy. The uterus was a mass of fibroids, and in other
circumstances I should have had no hesitation in doing hysterectomy. But
a child had been long desired, and this was obviously her only chance. I
removed ten fibroids, several being the size of a fist, and one partly necrotic.
Some were pedunculated, but several had to be enucleated from the substance
of the uterine wall. She had a normal confinement at term. The results of the
last two I have been unable to trace; in the remaining eleven pregnancy was
not interfered with, and all went to full time, except one whose labour came
on at seven and a half months, but the child was alive and survived. In
Case 8, the mother developed eclampsia and died, and the child was stillborn.
Two other children died a few days after birth from injuries during labour,
one being in a case of contracted pelvis. Both mothers had the satisfaction
of a living child subsequently; the one with the contracted pelvis being
delivered by Caesarean section.

It is evident that myomectomy during pregnancy is a most satisfactory
operation.

Table III.— Results of Myomectomy during Preqnancy.

No.

Age

| Date of operation

Period of
gestation

Result

January 11, 1909

4 months 1

1 Normal confinement on June 8, 1909 ; mother and
child alive

April 15, 1912

4} months

Normal confinement, August 25,1912; mother and
child alive ; this was the first pregnancy

March 17, 1913

3$ months

Normal confinement, September 8, 1913; mother
and child alive

October 14, 1914

4§ months

Confinement at 7$ months, January, 1915; mother
and child alive

October 7, 1915

; 3 weeks

Confinement, June 21, 1916 ; baby iniured at birth
and died three days later; confinement of a
healthy child in May, 1920

October 11, 1915

2 months

Confinement, May 10, 1916; contracted pelvis,
four days’ labour; child died shortly after;
became pregnant again, delivered successfully
by Ca»sarean section, January 16, 1919

April 17, 1916

6 months

Normal confinement, August 27, 1916; mother and
child alive

October 9, 1916

3 months

Confinement at full time; mother had eclampsia
and died ; child stillborn

December 30, 1918

8 months

Confinement, June 29,1919; instrumental delivery;
mother and child alive

November 25, 1919

a few days

Normal confinement, August 12, 1920; mother and
child alive

February 5, 1920

4 months

Normal confinement, July 5, 1920; mother and
child alive

March 4, 1920

3 months

Unknown

April 12, 1920

6 weeks

| Unknown

22 Bonney: The Scope and Technique of Myomectomy

The Scope and Technique of Myomectomy.

By Victor Bonnet, M.S.

(ABSTRACT.)

[This paper is published in full in the Lancet , October 7, 1922, pp. 745-748.]

The author said that myomectomy in principle fulfilled a higher surgical
ideal than hysteromyomectomy. He recorded a series of 100 consecutive
myomectomies to show that within wide limits neither the number or position
of the tumours in the uterus, nor the presence of degeneration, nor the accom¬
paniment of menorrhagia or pregnancy, were a bar to successful performance
of the operation. The largest number of fibroids that he had removed from
the uterus in a single case was thirty, but he did not regard this as the limit
of possibility. Anterior tumours were more favourably placed for enucle¬
ation than posterior tumours, because they could all be got out through an
anterior incision, but many posterior tumours could also be removed by the
same route. Malignancy and sepsis, of course, barred the operation, whilst
nsevoid degeneration made the operation more formidable, but with these
exceptions degeneration of the tumour or tumours had no bearing. In regard
to the technique of the operation, Alexander of Liverpool laid down the right
principle twenty-four years ago, i.e., an anterior incision in the uterus, and, if
possible, all the tumours removed through that one incision.

The author then proceeded to show by diagrams the manner in which the
enucleation cavities could be closed by suture. When fibroids were compli¬
cated by pregnancy, and an operation was required, myomectomy should be
combined with Caesarean section if the child was viable. If the child was
not viable the ideal procedure was to remove the tumours and leave the
pregnancy in situ; where many tumours were present, however, this was
impossible, and the pregnancy should be removed through the same incision as
the fibroids.

He had had two deaths in his series of 100 cases, all the other patients
had done well, and none of them had returned to him with new fibroids, or a
recurrence of the bleeding. Five patients had become pregnant subsequent to
the operation ; of these one had fourteen, another eight, and another five
fibroids removed, and two had one fibroid each removed. Four of these
patients had delivered themselves naturally. The remaining patient was
delivered by Caesarean section, but the condition of the uterus at this
second operation showed this method of delivery to have been unnecessary.
He hoped that in the future it would be common knowledge that fibroids did
not as a rule necessitate hysterectomy, and that if the possessors of these
tumours would only submit themselves to early surgical treatment their wombs
need never be removed.

DISCUSSION.

Dr. T. W. Eden (President) said that he was impressed by the excellence of the
results Dr. Giles had been able to report, and he thought that no better series of cases
had been placed on record. Apart from the question of mortality, it was very
encouraging that in only 10 per cent, of his cases which were followed up had there
been any reappearance of fibroids, and in only 20 per cent, recurrence of the menor¬
rhagia which was present before the operation. His results in pregnancy were also
remarkably good, for not a single instance of miscarriage had occurred in his thirteen

Section of Obstetrics and Gynaecology

cases, although it was generally agreed that myomectomy in pregnancy carried a 20 per
cent, to 25 per cent, risk of miscarriage. He agreed with the ideals expressed by
Mr. Bonney. He had always thought and always taught that the removal of the uterus
was surgically a very crude procedure to adopt in order to deal with a benign growth.
The surgically ideal procedure would be to remove the neoplasm and conserve the
organ in which it grew. His own practice had been to adopt myomectomy much more
freely than Mr. Bonney seemed to think was the case with most gynaecologists, and he
welcomed the efforts which were being made by the authors to call attention to its
advantages. He could not but admire the almost uncanny ingenuity displayed by
Mr. Bonney in removing fibroids of the posterior wall through an incision in the
anterior wall. At the same time he thought Mr. Bonney’s dread of an incision in
the posterior wall was quite groundless. It did not matter where the incisions were,
nor how many there were (within reason), so long as each one was properly closed with
complete haemostasis. There was no risk of bowel adhesions if the wound did not
ooze and the suture material was not infected. He did not employ mattress sutures
himself, but preferred to close the cavity left by enucleation of the fibroid in layers,
beginning from below and ending with the peritoneo-muscular wall of the uterus. He
had recently dealt with a large fibroid in pregnancy in this way, in which the
decidua had been exposed at the base of the enucleation cavity, but no ill effects
followed, and the patient carried her baby to term. He thought Mr. Bonney had been
unfortunate in having been obliged to evacuate the uterus in all but one of the
cases in which he had performed myomectomy in pregnancy. He felt strongly that
this should never be done in early pregnancy from choice, but only if technical
difficulties arose during the operation which rendered it unavoidable. The reason
for performing myomectomy in the early months of pregnancy was to relieve the
patient of her symptoms in order to allow pregnancy to continue to term.

Dr. Herbert Spencer thought the authors of the papers on enucleation of
myoma had performed a useful service in calling attention to the value of the operation,
which he supposed every gynaecologist practised, and preferred, in suitable cases, to
hysterectomy. He was surprised, however, to find no reference in either paper to the
most valuable form of enucleation, viz., through the cervical canal. The papers well
illustrated the pitfalls of statistics, Dr. Giles (after careful inquiry in a proportion of
his cases) giving the percentage of recurrence as 10, Mr. Bonney (without any
adequate inquiry) giving it as 0. No doubt the percentage was somewhat greater
than that found by Dr. Giles, and it constituted a serious objection to the operation,
especially when carried out by the abdominal route and with the added risk of ventro¬
fixation. Mr. Bonney’s method of enucleation was ingenious, but complicated and, in
Dr. Spencer’s opinion, unnecessary. One danger—the possible infected condition of
the tumours had not been alluded to. He had seen in a virgin a case of fibroids con¬
taining abscesses infected with streptococci, successfully treated by total hysterectomy.
The case, had enucleation been performed, would almost certainly have terminated
fatally, as had happened in a case in which a conservative Caesarean section was done
for an obstructing fibroid infected with bacillus of gas gangrene. Although infection of
fibroids which did not give rise to symptoms was rare, he thought it was important,
particularly in cases complicating pregnancy, that a bacteriological examination of the
tumour should be made before or at the time of the myomectomy. He agreed with
the President’s criticism of the frequent emptying of the pregnant uterus in perform¬
ing myomectomy.

Professor BRIGGS had long ago recognized the increasing sphere of enucleation in
the progressively earlier treatment of uterine fibroids : he appreciated the illustrative
modem reports within the papers just read. Allusion had been made to Dr. Alexander’s
work in Liverpool before 1898. At that time he (Professor Briggs) had convinced
himself by many laboratory tests of enucleation that the older fibroid growths,
degenerated and adherent to their capsules, were physically unsuitable for enucleation.
In his opinion enucleation was at its best when the scalpel could be thrust directly into
the substance of the fibroid, cutting it into halves or less, reducing its bulk and
providing for the insertion of an appropriately strong sharp hook for its extraction with

Discussion on Myomectomy

the minimum surgical interference with its capsular connexions. Fantastic uterine
tunnelling was unnecessary. It had to be borne in mind that after the most thorough
uterine palpation a fibroid growth might remain. He had only once in the enucleation
of a fibroid, acutely degenerated and adherent to the bladder (acute abdomen), had to
empty the pregnant uterus owing to the depth of the fibroid involving the placental
tissue of a three months male foetus. There could be no doubt that enucleation had
asserted its rightful place: but the fact of its dangerous and inconvenient abuse had to
be admitted.

Dr. LapTHORN SMITH said that he had done many myomectomies but they were
the exception. He agreed with the President in his statement that myomectomies
were the advanced stage of the operation for the removal of fibroid. Without the great
experience and technical skill which Dr. Giles and Mr. Bonney had acquired through
hundreds of operations of total hysterectomy they could never have obtained the results
which they had reported for their myomectomies. He had been surprised, however, to
hear that all Mr. Bonney’s cases of myomectomy in pregnant worsen had involved the
death of the child as in his own cases of myomectomy not one child was lost. First,
because he had only done myomectomy during pregnancy when the symptoms were
urgent; and secondly, because he had made liberal use of anodynes to keep the uterus
quiet for several days after the operation. He had always managed to shell out the
tumours without entering the uterine cavity. The presence of a fibroid in the uterus of
a pregnant woman which was not causing suffering rarely called for interference until
the child was viable. In his younger days the opinion was general in the profession
that the presence of a fibroid, especially in the lower part of the uterus, meant a
disastrous delivery. He remembered a whole morning at the International Congress
at Washington which was spent in discussing whether to bring on a miscarriage or to
remove the fibroid by hysterectomy as soon as discovered. It was now known that
nature not only got the fibroid out of the way of the coming child, but that sometimes
the tumour disappeared or at least became much smaller after the confinement.

Mr. L. C. RlVETT stated that he had assisted Mr. Bonney at a number of these
operations, and that the actual hole in the uterus was not as complicated as appeared
in the diagrams shown.

Section of ©bstetrice anb <5$iuecoloo\>:

JOINT MEETING WITH THE

Section of fCberapeutice anb pharmacology

Chairman—Dr. T. W. Eden (President of the Section of Obstetrics

and Gynaecology).

The Value of Ergot in Obstetrical and Gynaecological Practice;
with Special Reference to its Present Position in the
British Pharmacopoeia.

By H. H. Dale, C.B.E., M.D., F.R.S.

The subject proposed for discussion is : “ The Value of Ergot in Obstetrical
and Gynaecological Practice, with Special Reference to its present position in
the British Pharmacopoeia/* I think it is essential for a proper appreciation
of the problem that we should have before us a clear conception of the
pharmacology of the drug, and of the available information concerning the
chemical properties of its active principles. It is, obviously, my principal
function, in a discussion of this kind, to deal with this aspect of the matter.

The position of ergot in pharmacology and therapeutics is somewhat
anomalous. Like many other drugs it owed its introduction into therapeutics
to purely empirical observation of its effects. While no definite knowledge
existed as to the nature of its active principles, the methods adopted for
preparing the extracts, which have passed into official currency, were similarly
settled largely by tradition and experience at best vaguely recorded. I cannot
take time to-night to deal with the fascinating history of the subject. It is
sufficient for our purpose to note that about the middle of the last century
two types of preparation came into vogue. In one of these the extraction was
begun with water, and to the watery extract a certain proportion of alcohol
was added, which carried down what were regarded as impurities ; the other
preparation was made by a preliminary extraction with alcohol—the alcohol
being subsequently diluted with water, and the insoluble residue thereby
precipitated being again discarded. These processes appear to have provided
the basis for the two commonly used preparations in the British Pharmacopoeia
—the so-called extraction ergotae liquidum and extraction ergotae (or ergotine).
I shall have something to say of these preparations later.

The first substance obtained from ergot in a pure condition, which could be
regarded as having any probable relation to its pharmacological or therapeutic
activity, was the *' ergotinine ” of Tanret, which was isolated and described as
long ago as 1876. This beautifully crystalline alkaloid was associated with

F—Ob it Th 1 f December 7, 1922

, Dale: The Value of Ergot

a quantity of material appearing to Tanret to have an identical chemical
composition, but dififering from the crystalline ergotinine in resisting crystal¬
lization and in its low specific rotary power. Tanret regarded it as simply a
physical modification, and described it as “ amorphous ergotinine." A mixture
of these crystalline and amorphous alkaloids passed into use under the name
“ ergotinine," and acquired some therapeutic reputation, particularly in France.
Presumably the so-called “ergotinine citrate" is still obtainable and still
prescribed. I think it is clear, however, that Tanret’s conclusion that the
two alkaloids were identical delayed for some years a clear understanding of
the position. Subsequent workers, wishing to observe the pharmacological
action of ergotinine, naturally chose the crystalline form, which could be
obtained in a high state of purity, and found that it was practically inert. The
position became much clearer when my former colleagues, Barger and Carr,
succeeded in purifying the amorphous alkaloid by preparing crystalline salts
from it, and were thus able to show that it was chemically different from
the crystalline ergotinine closely related to it. My own pharmacological
contribution to the joint investigation showed that the amorphous alkaloid
yielding crystalline salts, now renamed 11 ergotoxine," was an intensely active
substance possessing the already known toxic actions of ergot—producing
gangrene and so forth—and being also the substance responsible for a new
and specific action of ergot, which I had shortly before identified. So far as
experiments in a laboratory enabled one to judge, ergotoxine might also have
been regarded as the principle responsible for the therapeutic action of ergot,
since it had a powerful stimulant effect on plain muscle—conspicuously of the
arteries and of the uterus.

There were several difficulties, however, in the way of the conclusion that
ergotoxine was the sole active therapeutic principle of ergot. I do not think
that it can be said that it received thorough and systematic clinical trial, but
such trials as were made at the time of its discovery did not arouse any
enthusiasm for its therapeutic properties. Again, the majority of practitioners
were using, in their obstetrical and gynaecological practice, the preparations of
the British Pharmacopoeia. The methods indicated for preparing these were
such as might almost lead to the suggestion that the aim of those devising
them was to exclude ergotoxine, so far as possible, from the official preparations.
No such aim, of course, existed. The methods were simply those long
hallowed by tradition. But, whatever the origin of these extracts, the fact
that they were so widely used, with apparent satisfaction, made it very
difficult to suppose that the only important principle of ergot was this alkaloid,
of which they contained, at best, very small traces. The argument, however,
was not a very strong one. A preparation, such as the fluid extract of the
United States Pharmacopoeia—an extract made with acidulated alcohol—
which contained a large proportion of the ergotoxine present in the ergot, was
standardized by certain producers by its power of producing gangrene of the
cock’s comb—an ergotoxine effect—and was, apparently, used with as much
satisfaction in America as the liquid extract of ergot of the British Pharmacopoeia
was used in England. There were other difficulties, however, created by the
claims of other pharmacologists to have discovered methods of measuring
the therapeutic value of an ergot extract by laboratory tests. My friend,
Professor Dixon, for example, stated that the therapeutic value of a liquid
extract of ergot could be measured by its power of raising the arterial blood
pressure of the cat; while, somewhat later, Professor Kehrer made the rather
plausible claim that the obvious way to measure the therapeutic activity of an

Sections of Obstetrics and Gynaecology and Therapeutics 3

ergot preparation was by its stimulant action on isolated uterine muscle.
Both these effects, indeed, are effects which ergotoxine produces, but the
preparations in which they were being measured by these authorities owed
their activities, in these two directions, not to ergotoxine at all—of which they
contained hardly any—but to entirely different substances, which my. colleague
Barger and I were able to identify as the bases tyramine and histamine, which*
can be produced from the amino-acids tyrosin and histidin by the action of
bacteria, which split off carbon dioxide.

An altogether new position was thus created. It was, of course, not
difficult to suppose that bases such as these, which are produced by many
bacteria, could also be produced by a fungus like ergot. So far as the evidence
went, however, it was against the supposition that they were present in the
drug itself before it was subjected to the process of extraction. The recent
very careful investigations of Stoll, carried out with very fresh and carefully
preserved specimens of ergot, confirm the view that these putrefactive bases
are not present in any significant amount in good samples of ergot itself.
This conclusion, however, by no means excludes the possibility that ergot
preparations, such as those of our Pharmacopoeia, might possess useful activity,
due not to the truly specific ergot alkaloids, but to bases such as these,
casually produced by the putrefaction, for which the officially prescribed
process of preparation provides abundant opportunity. At the same time,
there was difficulty in the way of supposing that bases like these, which are
undoubtedly present in many articles of diet, and which, further, are certainly
produced by bacterial action in the intestine, could have any great therapeutic
importance when administered by the mouth in relatively small quantities.

During the last two years a further complication appeared to be introduced
into this already tangled problem. Dr. Stoll, already mentioned, a Swiss
chemist working on behalf of a Swiss firm, isolated from ergot what appeared,
and still appears, to be a new alkaloid. Its properties are in many ways
closely similar to those of ergotoxine, but its formula, according to present
information, is slightly different, and it has the distinction of being susceptible
of crystallization as a free base. Experiments were made on its pharmaco¬
logical properties, by Professor Spiro of Basel; and a number of trials of its
therapeutic properties have already been published in the Swiss and German
literature. These, carried out far more systematically than any trials which
ergotoxine has ever received, seem to have satisfied the clinical workers con¬
cerned that this alkaloid, named “ ergotamine " by Stoll, has all the therapeutic
effects of good ergot, and produces these effects with more certainty and regu¬
larity. On the other hand, Professor Spiro’s preliminary investigation did not
make at all clear the relation of the pharmacological action of ergotamine
to that which I had, some fifteen years ago, described for ergotoxine. I
suggested to him that we should exchange preparations, and jointly make
the comparison, with the result that we were both perfectly satisfied that,
whatever might be their chemical relationship, these two alkaloids were
absolutely identical, both qualitatively and quantitatively, in their pharmaco¬
logical effects.

So far as the subject of our discussion is concerned, we may, therefore,
conveniently speak of these two known active alkaloids of ergot—ergotoxine and
ergotamine — as “the specific ergot alkaloids”; and the problem reduces
itself to this: Do the specific alkaloids of ergot give, in obstetrical or gynaeco¬
logical practice, or in both, the effects which the clinical worker wishes to
produce when he administers ergot ? If so, ergot must be included in the

Dale: The Value of Ergot

Pharmacopoeia, because these specific alkaloids can be obtained from no other
source. But, if ergot is to be retained in the Pharmacopoeia on account
of its specific alkaloids, the methods of preparing the official extracts ought
to be so revised as to ensure that these alkaloids are present in the finished
product, and not thrown away, as at present. If, on the other hand, it is the
fact that, with the existing official extracts, the non-specific putrefactive bases
which they contain possess all the remedial actions, in obstetrical or gynaeco¬
logical treatment, which ergot is supposed to produce, then it is equally clear
that ergot has no proper place in the Pharmacopoeia. These bases are much
more easily and cheaply obtainable from other sources, and by other methods,
and to provide them, for therapeutic use, by casual and unregulated putre¬
faction of an obscure and expensive fungus, is not a scientific or even a sensible
procedure.

I do not suppose that a discussion such as the present is likely to produce
all the necessary data for the final settlement of a question such as this, but
I may be allowed, in conclusion, to indicate one or two directions in which the
discussion might throw light on the problem. In the first place, it will possibly
clarify the issue if I indicate the relation of these known active principles to
certain non-official and proprietary preparations.

Ergotinine citrate is a preparation owing its activity entirely to the specific
alkaloids. Ergotoxine and its salts, when they were obtainable, were also
representatives of the specific alkaloids. The firm for whom Stoll carried out
his recent investigations are issuing a solution of ergotamine salts with the
name “ gynergen ” on the European continent, and “ femergin ” in this country.
The action of these solutions again is, of course, purely that of the specific ergot
alkaloids. Some years ago, Messrs. Burroughs Wellcome and Company issued,
in this country, a preparation to which they gave the name “ ernutin.” This
preparation was an attempt to avoid the difficulty of deciding between the
specific alkaloid ergotoxine and one or other of the putrefactive bases, as the
essential constituent of ergot, by including them all. During the war, and
since then, the practical disappearance from the British market of the ergot
from Russia, which was previously the source of ergotoxine, has, apparently,
led to a revision of this policy, and a preparation has, if I am correctly
informed, been produced in which the non-specific bases are retained, but the
unobtainable ergotoxine has been omitted. There may be those present who
have had the opportunity of testing both mixtures, and who may be able
to say whether the mixture containing the non-specific bases only has any
of the activity expected of ergot, and, if so, whether it has as much
of that action as the preparation also containing the specific alkaloid—
ergotoxine.

There is one other point which suggests itself to my ignorance as possibly
worth consideration. Ergot used to be employed very largely in obstetrical
work. I imagine that, in this direction, its use has largely been displaced by
that of the pituitary extract. In so far as it is still used, it appears to me
that there is just a possibility that the type of ergot action, and, therefore,
the type of ergot preparation, which is desirable in obstetrical practice, may be
different from those which are required in gynaecological work, in which, I
gather, ergot nowadays finds its principal application. I venture to suggest
that the possibility of this distinction may with advantage be kept in view in
our discussion.

It is, as I said, almost too much to hope that a discussion like this can
finally settle a question of this kind. It will not be fruitless if it makes clear

Sections of Obstetrics and Gynaecology and Therapeutics 5

the nature of the question which requires settlement. I feel very strongly
that the present position of ergot and its official extracts, in our Pharma¬
copoeia, is something of a reproach to a scientific profession. Possibly, from
this discussion, some suggestion may emerge of an organized investigation by
which the reproach may be removed.

DISCUSSION.

Sir NESTOR Tirard said that since the value of ergot was to be discussed with
special reference to its present position in the British Pharmacopoeia, he felt it his duty,
as one of the editors, to make a few remarks upon that subject. In particular he
wished to refer to the statement about the methods of preparing the extracts being
44 those long hallowed by tradition.’* This appeared to suggest that very little trouble
had been taken in the compilation. It might be well to say that before revising the
44 list of medicines and compounds and the manner of preparing them ” (Medical Act
of 1858) those responsible took many steps in their endeavour to ascertain the wishes of
the medical profession. All the authorities—that is the examining or licensing bodies—
were asked to make suggestions for additions, omissions or alterations. Replies were
received from nineteen authorities and were tabulated. The detailed views of the
Therapeutic Committee of the British Medical Association, the representations of a
committee of wholesale firms, and an analysis of some forty-eight thousand recent
prescriptions also supplied material of great value. It was found that in no single
instance was there any desire to onfit ergot or its preparations. One authority
suggested the introduction of a stable active principle of ergot, another considered that
the preparation of extractum ergotae might be improved, and a third wished the liquid
extract to be standardized physiologically. The last was an attractive proposal for
preparations of several other drugs besides ergot. In the absence of a State laboratory
to establish a standard there were obvious difficulties at the time the current Pharma¬
copeia was undergoing revision. He (Sir Nestor Tirard) expressed full appreciation of the
valuable work of Dr. Dale upon ergot. He noticed, however, that Dr. Dale, in a recent
report upon pituitary extracts, 1 had shown that claims of physiological standardization
already made on behalf of some five different commercial samples included wide
divergencies of activity. An authoritative standard and a State laboratory were
essential before it would be possible to introduce pituitary extract into the British
Pharmacopoeia, even though pharmacologists and obstetricians might be agreed that it
should replace ergot.

Dr. Herbert Spencer thought Dr. Dale’s paper was of great value, not only in
its pharmacological aspect, but also in emphasizing the importance of the collaboration
of laboratory and clinical workers. He had had evidence of this at University College
Hospital, where, in the laboratory of the medical unit, the discovery of the weakness of
a supply of pituitrin had led to its abandonment and the substitution of an efficient brand.
He said that Dr. Kellaway had also investigated a new r preparation of ergot which showed
a very powerful effect; but the uterus did not react to repeated doses. He (Dr. Spencer)
had therefore decided not to use it clinically. There was no doubt of the power of
liquid extract of ergot to cause the uterus to contract; but for gynaecological bleeding
he found the ammoniated tincture much more efficient and had used it exclusively for
thirty years. He had therefore been interested to hear Dr. Dale’s opinion as to
its pharmacological superiority.

Professor W. E. DlXON, F.R.S., regarded as one of the most important advances of
the last few years the discovery that the substances that worked the human body were
not far removed from the crystalline alkaloids that could be isolated. It appeared
likely that the normal stimulus to the uterus was the secretion of the pituitary gland
into the cerebro-spinal fluid. An interesting point was that the injection of ovarian
extract alone among organic extracts led to the appearance of pituitary secretion in the
cerebro*spinal fluid. Corpus luteum did not cause this phenomenon, but the substance

1 See Lancet , November 25 , 1922, p. 1134.

Discussion on the Value of Ergot

of the ovary itself did so even after it had been boiled. It would seem to follow that
uterine contraction w r as a physiological process brought about by pituitary extract.
It was therefore interesting that obstetricians apparently preferred pituitary extract to
any other drug for the purpose of stimulating uterine muscle. In Germany in 1915
a number of experiments had been performed in which the movements of the human
uterus w'ere recorded. A comparison of the effect of ergot with that of pituitary extract
showed that after the administration of the latter the pains became quicker, but no
difference in tone was detectable, whereas after ergot the pains increased and the tone
also increased. With regard to the British Pharmacopoeia, pharmacologists were clear
that the American liquid extract was far superior to the British liquid extract.
Sir Nestor Tirard had intimated that the editors of the British Pharmacopoeia were out
to produce standards of those drugs which were commonly used—i.e., that they were
prepared to follow in the wake of, but did not attempt to lead the profession. How,
then, should we advance *? Practitioners tended to follow the British Pharmacopoeia as
an authority guiding them as to which preparations of drugs they should use. In this
way a circle was established, from which there appeared to be no escape.

Dr. T. W. Eden (Chairman) said that they greatly appreciated Dr. Dale for his very
clear and interesting presentation of the subject. Although Dr. Dale had spoken with
modesty of his own share in the w ork w r hich had been done, there was no doubt that
he had done a great deal to clear up the confusion which had existed with regard
to the active principles of ergot. He (the Chairman) thought that although they now-
had, in pituitary extract, a reliable substitute for ergot, it would be very unfortunate if
ergot disappeared from the Pharmacopoeia because it w'as a much more suitable drug
than pituitary extract to place in the hands of midwives. Pituitary extract occasion¬
ally produced rather alarming toxic effects, and its potency called for great care when
using it, whereas ergot was free from any risk of producing unfavourable general effects
in obstetric practice. The reluctance of clinical workers to discuss the subject was
perhaps explained by the deep distrust which they all felt for clinical impressions of the
action of drugs. There were so many possible sources of error that very great care
w ? as called for in attributing clinical phenomena to drugs which had been administered.
In the case of ergot he had always felt that it ought to be possible to devise a method
of graphing the uterine contraction in labour by means of a bag placed in the cervix,
and if the pharmacologist could help them to work out such a method, the action of both
ergot and pituitary could be subjected to an accurate clinical test.

Mr. Aleck Bourne said that he was now engaged in an attempt to measure
accurately and graphically the changes of intra-uterine pressure induced by the injection
of pituitary extract, on behalf of the Committee appointed by the Council of the Section
of Obstetrics and Gynaecology for the Investigation of Pituitary Extract in Labour.
The apparatus which w’as made and supervised by Dr. H. H. Dale and Dr. Burn had
so far w r orked very well, and it was hoped that the report of the Committee, when
published, would refer to results of real value obtained by this direct method. He
further mentioned this work on pituitary extract to suggest a method by which some
scientifically accurate evidence of the value of ergot and its derivatives on the human
uterus might be obtained, as he had very little confidence in the scientific value of the
impressions gained by the clinical administration of the drug. He feared the effects
of bias in favour of, or against, the use of a particular drug were too strong—perhaps
unconsciously so—to enable the observer to arrive at a scientifically accurate opinion
from clinical evidence alone.

Professor Henry Briggs appreciated Dr. Dale’s interesting summary' of the past
of ergot, also his laboratory search for the best in ergot. The drug had attained a
varied reputation, and established clinical opinions against its efficacy were readily
recalled. Wider co-operation in laboratory and bedside work was rightly advocated
by Dr. Dale. Professor Briggs stated that during the past five years he himself had
often officially referred to the singular practice in medical schools of issuing daily from
the theatre long lists of common and rare operations and of not issuing similar ward
notices of the medical cases with an indication of the main remedy or drug in use in

Sections of Obstetrics and Gynaecology and Therapeutics 7

each. In any medical school, the issue of such medical ward notices was little more
than a bare duty to the laboratory of pharmacology; the notices would be welcomed as
guides to students and visitors.

Dr. Dale (in reply) said that the position Sir Nestor Tirard had taken up as
to the functions of the British Pharmacopoeia, was quite intelligible but rather hopeless.
The function of the British Pharmacopoeia was not to lead but to follow the profession.
There would never be progress on those lines, for the profession was apt to regard
the British Pharmacopoeia as an authority not only as to what was, but as to what
should bp, used. In the 1914 British Pharmacopoeia the extract of ergot had been
changed from an alcoholic to a watery extract.

Sir Nestor Tirard at this point reminded Dr. Dale that the British Pharmacopoeia
was controlled by an international agreement whereby it was compelled to make all
liquid extracts watery extracts, alcohol being added subsequently. In America alone,
in spite of this agreement, had the alcoholic extract been retained.

Dr. DALE said he wished that the American disobedience had prevailed in this
country also, because by other methods the specific active substances in ergot were
thrown away and the adventitious substances—he might almost say impurities—were
retained. The Chairman (Dr. Eden) had spoken of the advantages of extracting all
the active principles of ergot. This would limit the preparation to one containing the
alkaloids, since the bases practically did not exist in fresh, clean ergot. Mr. Bourne
had been pessimistic as to the help available from clinicians, and Dr. Dale agreed that
a Committee reporting to the Section of Obstetrics and Gynaecology would probably be
the best method of eliciting any information of value. Presumably the findings of
such a committee of obstetricians w'ould carry some weight with the editors of the
British Pharmacopoeia.

Section of ©bstetrtcs ant> <B$n#colo(j£.

President—Dr. T. W. Eden.

A Specimen of Primary Carcinoma of the Vagina.

Shown by Eardley Holland, F.R.C.S.

The patient was aged 46, had four children, and still menstruated regularly ;
for five months she had had an offensive, watery, blood-stained vaginal dis¬
charge ; for the last two months there had been a good deal of haemorrhage,
but no pain. On examination a hard, circular, raised, rough, friable growth
was found on the upper third of the posterior vaginal wall. The upper edge
of the growth was separated from the cervix by half an inch of healthy
vaginal mucous membrane. The cervix looked and felt normal, the uterus
was normal in size and position, and there was no palpable evidence of
other pelvic disease. Rectal examination did not reveal any infiltration of
the anterior rectal wall, which could be moved freely over the posterior surface
of the growth.

The operation was performed under stovaine spinal anaesthesia and open
ether on October 20, 1922, the whole of the vagina and uterus, together with
the pelvic cellular tissue and iliac lymphatic glands being removed. The patient
was first placed in the lithotomy position and an incision was made all round
the lower end of the vagina, which was dissected up from its attachments,
partly by blunt dissection and partly with scissors; no difficulty was experi¬
enced with this dissection, and there was remarkably little bleeding. There
was no adhesion between the vaginal wall at the site of the growth and the
rectum, and there was no evidence whatever of infiltration of the anterior
rectal wall. After the vagina had been separated as high up as the cervix, its
lower end was inverted and sewn up. The vulva was then packed with gauze,
the patient was placed in the Trendelenburg position, and the usual stages of
Wertheim’s hysterectomy were proceeded with. The only difficulty was
encountered when the upper end of the vagina w r as being separated from the
bladder. At this stage it was apparent that the plane of separation found was
different from that found during the separation of the vagina from below ; it
was evident that, whereas from below the separation was mesial to the vesico¬
vaginal fascia, in the abdominal part of the operation the plane of separation
was outside this fascia. The correct plane was soon found, and there was no
difficulty in completing the operation and removing the uterus, together with
the whole of the already separated vagina, through the abdominal wound.
After the peritoneum had been sewn over the pelvic floor in the usual way, the
abdomen was closed and the patient again placed in the lithotomy position.
Upon removal of the pack from the cavity left by the excision of the vagina,

Mh —Ob 1 [January 1, 1928.

26 Holland : Carcinoma; Stevens: Squamous Epithelioma

very free oozing was found to be going on from the upper end of this cavity ;
this had been caused, no doubt, by the separation of the upper end of the vagina
through a plane different from that used in the vaginal part of the opera¬
tion. As control of this oozing with forceps and ligatures proved trouble¬
some and lengthy, the cavity was packed with gauze soaked in flavine
solution, and the patient was put to bed in very fair condition. Con¬
valescence ran a smooth course, and was complicated only by suppuration
in the lower part of the abdominal wound. Histologically the growth
proved to be solid, trabecular, squamous and horny-celled carcinoma of the
vagina.

Owing to the close proximity of the posterior vaginal wall to the rectum,
and to the very small amount of intervening cellular tissue, it seems almost
certain that in these cases permeation of the carcinoma cells into the anterior
rectal wall must take place at a very early stage of the growth. The question
therefore arises as to whether it is not also advisable to remove the lower
part of the rectum, although the operation would then become an extremely
severe one.

I should like the opinion of the Section on this point.

Specimen of Squamous Epithelioma of the Vagina.

Shown by Thomas G. Stevens, F.R.C.S.

The patient, Mrs. M., aged 53, had noticed a coloured discharge for two
months previously to June 1, 1922, when she was first seen. The periods had
almost ceased, only a small loss on one day each month for three months
having occurred. There was pain in the pelvis, there was also great sense of
weight and pressure, with pains down the legs. For some years she had been
wearing a large Hodge pessary for prolapse, but this had been discontinued for
a year or more.

On examination a large flat growth was found on the posterior vaginal
wall, which at first was thought to be an extension from a cervical growth,
but this was found at the subsequent operation not to be the case.

The uterus and upper half of the vagina with the whole growth were
removed by abdominal pan-hysterectomy, after isolation of the ureters. The
operation was not particularly difficult, the growth apparently not having
involved the rectal wall in any way. No secondary glandular deposits were
found. The patient made an uninterrupted recovery and eight weeks after
the operation received a large dose of X-rays with the object of preventing
a recurrence. Up to the present the patient remains quite well.

The growth wffiich, roughly speaking, is the size of a five-shilling piece,
occupies the posterior vaginal wall, and is separated from the cervix by about
half an inch of unaffected vaginal tissue. The external os uteri show’s some
redness and roughening of the surface, the result of infection and inflammation,
but does not present any evidence of malignant growth. The body of the uterus
contains one fibroid.

The growth proves to be a squamous epithelioma histologically.

Section of Obstetrics and Gynaecology

DISCUSSION.

Dr. H. Russell Andrews said that he was interested in the remarks of Mr. Holland
and Mr. Stevens as to the best method of removing the vagina in such cases. He said
that in March, 1909, he showed a specimen of primary carcinoma of the vagina before
this Section. 1 The patient, a multipara, aged 62, had complained for six months of a
blood-stained watery discharge and loss of flesh. There was a carcinomatous ulcer, the
size of a two-shilling piece, high up on the posterior vaginal wall. The cervix was not
involved. He removed the whole vagina and uterus from below. As soon as the lower
part of the vagina had been freed, a large curved clamp was put on, which converted
the vagina into a closed bag; this was done with the idea of preventing any scattering
of carcinoma cells. The operation was performed in September, 1907, over fifteen
years ago, and there had been no recurrence. The patient, who was now 77, had been
seen by Dr. Andrews on January 8, 1923, and found to be in excellent health. Dr.
Andrews considered that if the rectum was involved the case was too far advanced for
operation. He did not think that routine removal of the rectum was justifiable in cases
of carcinoma of the vagina.

Mr. CLIFFORD White said he thought that the question raised by Mr. Holland of
excising the rectum as well as the uterus and vagina in advanced cases was important.
He had done this operation on one occasion by an extension of the ordinary abdomino¬
perineal method for excision of the rectum. The operation itself was not especially
difficult, but he had experienced the greatest difficulty in covering in the large cavity
left, owing to the deficiency in peritoneal flaps. In spite of the presence of a large
plug inserted from below, a loop of small gut prolapsed, and the patient died with
symptoms of intestinal obstruction on the fifth or sixth day.

Adenoma of the Vaginal Fornix simulating Cancer of the

Cervix.

By Herbert R. Spencer, M.D.

E. F., AGED 54, admitted to University College Hospital on June 30, 1920,
had had two children and one miscarriage, the last pregnancy having occurred
twenty-seven years ago. She had been a widow for twenty-five years. She
had suffered from intermittent haemorrhages from the vagina since September,
1919. The blood was very dark and clotted, and was followed by a slightly
coloured discharge. Sometimes the patient had gone for a month without any
discharge at all. Pain was absent except when the clots were being passed.
The patient had been getting thinner during the last month. There was no
history of cancer or tumour in the family. Menstruation began at the age of
15, had always been irregular (at intervals of four to six weeks), lasted three to
four days and required five to six diapers. The menopause occurred six years
ago (at the age of 48) and there had been no bleeding afterwards until nine
months ago. There was no trouble with micturition, beyond slight frequency
in the daytime ; the urine was normal, except for a deposit of phosphates ; the
bo^vels were confined ; there was no history of the performance of any vaginal
operation with the exception of forceps deliveries.

The patient, a grey-haired, moderately nourished woman, with a well-
marked moustache, looked unhealthy and somewhat cachectic. Nothing
abnormal was to be felt in the abdomen. The perineum had been torn in one

1 Proceedings , 1909, ii (Obst. and Gyn. Sect.), p. 248.

Spencer: Adenoma of the Vaginal Fornix

of her confinements, and stitched. There were some scars in the vagina ex¬
tending from the perineum (and, after removal of the tumour, a triradiate scar
was seen in the posterior fornix). On passing the finger into the vagina a
brittle growth as big as a large duck’s egg was found nearly filling the
vagina. It bled very freely, and prevented examination of the upper vagina.
The tumour was irregular on the surface and exactly resembled a proliferating
carcinoma of the cervix, and I had no doubt that it was of that nature.

My purpose to remove the vaginal mass as a preliminary to an extended
abdominal hysterectomy was easily effected by breaking away the growth in
pieces with the fingers. Having done this, on passing a 'speculum, I was
surprised to find that the growth, which had been completely removed by the
fingers, had been attached to the fornix of the vagina to the left and front of
the cervix. The cervix itself was normal, except for two minute mucous polypi,
which were snipped off. The raw surface where the tumour had been attached
measured lj in. in length and $ in. at the broadest part (in front) as shown
in the sketch taken at the time (fig. 1) ; it resembled a superficial tear in the
vagina. The shallow wound was slightly infiltrated with blood ; but there was
no induration at its base or in its neighbourhood, and the uterus itself was

Fig. 1.—Showing area of attachment of the adenoma.

normal and freely movable. As the wound oozed slightly a plug of iodoform
gauze was applied and a piece of the growth was hardened and cut; the rest of
the tumour was not kept. Although it appeared to be a benign tumour, on
July 3, 90 mg. of radium emanation were applied to the raw surface for twenty-
five hours: on July 10 the surface was only % in. in length, quite smooth and
pink in colour. The patient left the hospital on July 15, and was examined on
August 15, when the wound had cicatrized. I examined the patient on
April 4, 1922, and found her quite well, and the vagina and uterus healthy.
A letter was received from her on December 14, 1922, stating that she
remained in good health, nearly two and a half years after the operation.

Microscopical Examination .—What appears to be the surface is covered
with a single layer of columnar epithelium, in places thrown into papillae. The
tumour consists of glands lined with a single layer of columnar epithelial cells
(with large well-stained nuclei) set in a fibro-muscular stroma which forms well-
defined bands and areas in some parts of the tumour, and in others is so scanty
that the glands lie closely apposed. There is slight small-cell infiltration of
the stroma, and in parts haemorrhage has occurred, probably owing to the

Section of Obstetrics and Gynsecology 29

trauma of the operation. The glands are sometimes simple tubes, in other places
are nearly filled with papillary projections and have a markedly convoluted
appearance (fig. 2). There is no sign of penetration of the basement membrane,
and the epithelium is everywhere in a single layer and of simple aspect. Only
in the neighbourhood of the haemorrhages is the epithelium a little swollen,

Spencer: Adenoma of the Vaginal Fornix

vaginal fornix simulating cancer of the cervix must, I think, be very rare; I
have not come across the record of a similar case. It points to the value of the
removal of redundant growths before resorting to the extended abdominal
hysterectomy. It is remarkable that such a large growth should have had a
narrow band-like pedicle, and that removal of the growth with the fingers was
sufficient to effect a cure ; for I do not think the radium can be credited with
the result. An interesting subject for speculation is the origin of the growth.

Fig. 3.—Illustrating Dr. Spencer’s case of adenoma of vaginal fornix.

The position suggests that it may have originated in an isolated portion of
Gartner’s duct; or perhaps it may have taken its origin in the crypts which
are sometimes found in the vaginal fornix.

Dr. HERBERT SPENCER said that Mr. Bonney’s case, which had been referred to by
a speaker, was one of disseminated, inflammatory, sessile glandular structures, quite
unlike the large pedunculated cancer-like adenoma he had shown. He agreed with the
criticism that it was unlikely that it originated in Gartner’s duct.

Section of Obstetrics and Gynaecology

A Uterus removed for Carcinoma of the Cervix after
Treatment by Radium.

By A. H. Richardson, F.R.C.S.

This is a specimen of a uterus which was originally the site of an extensive
cervical carcinoma in which, first, a laparotomy was done and the growth
judged to be inoperable; secondly, two applications of radium were made at
an interval of three months, followed by apparent disappearance of the growth ;
and thirdly, the abdomen was again opened and a radical hysterectomy was
done without much difficulty.

The patient first came under observation in June, 1921, as a case of
carcinoma of the cervical canal, with* slight extension to the vaginal portion.
She complained of continuous haemorrhage, offensive discharge, and backache.
She was nulliparous and aged 51. The menopause had taken place eighteen
months previously. Symptoms had been present for nine months. She was
admitted to hospital and an attempt was made to remove the uterus, but this
was given up on account of the fact that in'the act of separating the bladder
from the cervix a portion of growth was actually opened up.

Three weeks later the first application of radium was made. A quantity of
typical friable growth was scraped out of the cervical canal, so that a cavity
remained, into which the terminal joint of the index finger easily passed.
In this cavity two tubes of radium of 50 mg. each were placed, each screened
with a silver filter of 2 mm. in thickness, and rubber tubiug of 1 mm. in
thickness. These were left in position for thirty-six hours.

Three weeks later the patient was seen at the out-patient department and
reported that all her symptoms—haemorrhage, discharge, and pain—were much
alleviated. She did not appear again for about a month, and then said that
the haemorrhage had recommenced though it was not so severe as before.
She was readmitted and another application of radium was made. It was now
found that one tube of radium could only be passed with difficulty—and that,
after some use of a sharp spoon—into the cavity which before had been a large
hole easily excavated out of the cheesy growth. This tube, as previously,
contained 50 mg. of radium, and was similarly screened with 2 mm. of silver
filter and 1 mm. rubber tubing. It was left in position for thirty-six hours.
A second tube was placed transversely across the vaginal vault and held in
position with a gauze pack. This was removed in twenty-four hours.

The first operation took place in June, 1921; the first radium application
was made in July, 1921, and the second in October, 1921.

The patient next appeared in early December, 1921, when she said that
there had been no further haemorrhage nor discharge, but that she had had
a good deal of pain in the back (sacral pain). On bimanual and vaginal
examination it was found impossible to say whether there had ever been any
growth, so it was thought that now was the time to remove the uterus.
She agreed to this and a card was sent to her just before Christmas, 1921,
telling her to come into hospital. She failed to appear and wrote to the Sister
saying that her husband was ill and that she had to nurse him. After this we
completely lost sight of her until six months later, June, 1922, when she
reappeared in the out-patient’s department one day, saying that she had not
been able to come before as her husband had been ill and had died very
recently. The condition was exactly the same as in December, 1921. There

32 Richardson: Carcinoma; Eden & Goodwin: Cancer of Cervix

was no demonstrable growth. She was admitted and a radical hysterectomy
was performed. Where, before, growth had been encountered in separating the
bladder from the cervix, there was now an area of dense cicatricial fibrous
tissue which presented the only, but rather formidable, difficulty of the
operation. Once past this cicatricial area the bladder was separated from
the upper part of the vagina with ease; the ureters were isolated without
difficulty and were not involved in any sort of pathological tissue, fibrous or
otherwise. There were no enlarged glands to be seen nor felt in the pelvis.
She left the hospital five weeks later and went to a convalescent home.

Dr. Dudgeon examined the uterus and reported that, macroscopically, he
could see no growth. He cut sections from four different parts of the cervix
and only in one did he find a small focus of carcinoma, and that was very
atypical. To put it in his own words, “ the carcinoma cells are very shrunken
and look as if they had been boiled.”

There is a great deal of fibrosis of the whole cervix and the mucosa has
largely disappeared.

Two Cases of Cancer of the Cervix treated by Radium

before Operation.

By T. W. Eden, M.D. (President), and Aubrey Goodwin, M.D.

Case /.—A. D., a multipara, aged 53, was admitted to the Chelsea Hospital
for Women on January 17, 1922, complaining of vaginal discharge and pain in
the back and left groin of three months' duration. Previously to the onset
of the symptoms menstruation had been regular and normal, and her general
health was good. Examination showed an extensive, friable growth covering
the whole cervix, and extending over the left and posterior vaginal walls for an
area of about 2 cm. in diameter. The mobility of the uterus was a good deal
impaired. On January 26, scraping the growth with a sharp spoon showed
that considerable invasion of the cervical tissues had occurred, and into the
large cavity thus formed a tube containing 200 mgm. of radium bromide was
introduced, and left there for twenty-four hours. The patient was not examined
again until February 21, nearly a month later: no trace of the growth could
then be found on examination with the finger or by inspection through a
speculum. The cervix was smooth and the external os of normal size ; the
vaginal walls were smooth and apparently healthy in the position previously
occupied by the growth. Wertheim’s hysterectomy was performed on
February 23. No difficulty was experienced in freeing the ureters, and there
were no enlarged glands found. Convalescence was uneventful.

Pathological Report by Dr. Aubrey Goodwin.

Macroscopical .—A uterus, 9 by 6 by 3*5 cm., removed by total hysterectomy
together with the appendages of both sides and a cuff of vagina 0*5 cm.
in length. The peritoneal surface of the uterus is smooth. On the posterior
wall of the vagina there is a healing granulating surface. The vaginal portion
of the cervix is excavated but its surface is smooth. On section the endocervix
has been found to be occupied by a fungating granular growth which spreads
upwards towards the body of the uterus and downwards towards the vaginal

Section of Obstetrics and Gynaecology

portion of the surface. The walls of the uterus are up to 1'8 cm. thick, the
endometrium is 0‘5 cm. thick, pale and villous. The tubes and ovaries are
atrophic.

Microscopical .—There is an extensive spheroidal and columnar-celled adeno¬
carcinoma of the upper part of the cervix. The vaginal portion of the cervix
and the posterior wall of the vaginal cuff show a healing granulating surface
with no malignant cells to be seen. The endometrium shows a type of villous
endometritis but in the zone near to the internal os the cells are beginning
to show definite malignant changes. The ovaries show senile fibrotic changes.

Case II. —L. S., multipara, aged 47, admitted to the Chelsea Hospital for
Women on October 23, 1922, complaining of a blood-stained vaginal discharge
of five months’ duration. Previously to this, menstruation had been regular
but profuse. The general condition was good and she had had no pain.
Examination showed a large irregular friable growth of the cervix which
practically filled the upper part of the vaginal canal; the growth extended
upon the vaginal wall on the right side for a short distance. The body of the
uterus contained a hard fibroid the size of a large apple. The mobility of
the uterus was not much impaired. On October 25, after the friable growth
had been scraped, 160 mg. of radium bromide were introduced in three tubes,
and left for twenty-four hours. The pathological report on the scrapings was
“ columnar-celled papillary cancer of the cervix.” The patient was examined
again on November 9, i.e., fifteen days later, and no trace of growth could be
found. The walls of the cervix appeared smooth and healthy. The uterus
was removed by Wertheim’s hysterectomy on November 9 ; the operation was
simple and easy and there were no enlarged glands.

Pathological Report by Dr. Aubrey Goodwin.

Macroscopical. —Uterus, 10 by 8 by 12 cm., removed by total hysterectomy
together with the appendages on both sides and a cuff of vagina 3 cm. in depth.
In the posterior wall of the uterus is a single large fibromyoma 8 cm. in
diameter. Projecting into the cavity are two small polypoid projections
of endometrium 0*8 cm. long. The cervix is hypertrophied and tough, with
several hard whitish areas in its substance. The ovaries are tough and
fibrous.

Microscopical .—Three sections : (l) Wall of uterus and polypus ; (2) tough
area in cervix; (3) cervix and vagina. Section (l) : Benign glandular
hyperplasia and hypertrophy of endometrium—“ polypoid endometritis.”
Sections (2) and (3) : Columnar-celled adenocarcinoma of cervix undergoing
hyaline degeneration. The fibro-muscular tissue of the cervix is also showing
hyaline changes. There is an extensive round-celled infiltration of the growth.

Remarks by Dr. T. W. Eden (President).

I think that in future malignant disease will be treated by a combination
of wide surgical removal of the growth with free use of methods of radiation.
In the case of cancer of the cervix there are certain notable advantages in the
use of radium before operation. In the first place a proliferating growth can
be almost entirely got rid of by a single application of a sufficiently large
amount of radium : this greatly simplifies the subsequent operation, and may
even render clamping of the vagina below the level of the growth unnecessary.

Eden and Goodwin: Cancer of Cervix

In the second place the risk of cancer implantation occurring during the
operation is greatly reduced, for the sections show that the cancer cells which
remain in the zone of irradiation are much degenerated, and are probably
incapable of being grafted successfully upon fresh tissues. In the case of
a widespread growth such as that found in Case I, the strictly local action
of the radium is well shown, the portion of the cancer most distant from the
external os being little affected. On this account as much as possible of
the growth should be removed with the sharp spoon, so that a cavity in which
the radium tube can be buried may be obtained and thus brought in contact
with the distant parts of the growth.

DISCUSSION.

Mr. Malcolm Donaldson said that this subject was being investigated by Dr.
Canti and himself on behalf of the Gynaecological Department at St. Bartholomew’s
Hospital. So far fifty-five cases had been treated and the majority had been benefited
for a time. In his opinion it was much too early to discuss the ultimate value of the
treatment. It was quite obvious that the carcinoma could be destroyed locally in the
cervix, but the problem remained how to free the parametric tissues and glands. At
present he was trying two methods : (1) Deep radiation by the operation devised by
Dr. Frans Daels (of Ghent); (2) by X-ray treatment. The most urgent need at present
was a scientific basis for dosage. He was very doubtful whether the biological effect
was the same if the amount of radium was doubled and the duration of exposure halved.
He said that a chart of the histological findings drawn up by Dr. Canti very strongly
suggested that the time-factor and distribution of the radium were perhaps more
important than the quantity of radium.

Mr. Sidney Forsdike said that the authors had mentioned the weight of radium
and the length of time for which it was employed, but that information was of small
value unless they also gave some account of the screens utilized. This was most
important, for a paper, published by Wood and Prime in the Annals of Surgery some
years ago, showed conclusively that the hard Beta-ray plus Gamma-ray was approxi¬
mately eight times as potent as the Gamma-ray when used alone. There was no
question of the immediate dramatic improvement in the most advanced cases of
carcinoma when treated by radium, and it might be said that as a palliative it was the
treatment of choice. With apparent cures one must always regard indurated tissues
with suspicion, for they too frequently contained a potential neoplasm. As to the
Belgian operation for treating the pelvic glands and cellular tissues by radium, it was
retrogressive in principle and added another terror to the disease; opening the abdomen
and implanting radium into the growth had obvious limitations, and the only method
of dealing with such deposits was by means of the hard X-ray treatment. Recasens
had been treating carcinoma of the cervix with radium applied locally and X-rays
applied to the rest of the pelvis, and he claimed improved results upon treatment with
radium alone. The question arose whether radium should not be used at an earlier
stage of the disease; Burrows (Manchester) only treated advanced cases referred to
him by surgeons, and reported 12 per cent, of them as remaining free of the disease for
from three to four and half years, but concluded that this was the best he hoped for
with the advanced cases with which he dealt. Three early operable cases had been
referred to him (Mr. Forsdike) owing to the physical condition of the patients; one
died within a month of the first exposure, with an acute toxaemia, and there was reason
to suspect the selenium, with which she was also being treated, as the cause of it.
One of the others had had three exposures and remained free from signs and symptoms
one and half years afterwards. The third had four exposures of radium and subsequently
hard X-rays to the pelvic tissues; she remained well eighteen months afterwards. No
conclusion as to the efficacy of this treatment could be drawn from the result in three
cases only, but the benefit derived from it in suitable cases was encouraging.

Mr. GORDON Luker said that for the past two years he had been employing radium
previous to operation in all cases. He had been inserting 50 mg. of radium into the

Section of Obstetrics and Oynsecology

cervical canal for thirty-six hours and the application had been made from one to seven
days before the operation. His idea was that by this means the dissection was made
through “ radiumized ” tissue and that recurrence was thereby prevented. In nine
cases followed up from nine months to two years there had, so far, been no local
recurrence. In a few cases another application of radium had been given three months
after the operation. He was not so enthusiastic about the use of radium in bad
inoperable cases, but in doubtful cases he had seen the growth almost disappear, so
that operation could be easily performed later. In one such case of a year ago,
operation five months after the application of radium had been very easy and no
recurrence had taken place.

Dr. H. Williamson said that every case of carcinoma of the cervix admitted to
St. Bartholomew’s Hospital during the last eighteen months had been treated by radium
before operation. Some details of these cases had already been given by Mr. Donaldson 1
and although it was too early to speak of results, facts of importance had been demon¬
strated. First, it had been shown that in early cases in which the irradiation was
distributed over the cervix by means of a number of needles in addition to a tube
inserted into the cervical canal, sections taken from many parts of the cervix after
Wertheim’s operation failed to reveal the presence of cancer cells. Secondly, it had
been shown that cases originally considered inoperable in some instances became
operable after three or four irradiations. Thirdly, it had been shown that it was
dangerous to treat septic growths by radium : in two cases in which the growth was in
a sloughing and necrotic condition a fatal pyaemia had followed the application of
radium.

Glycosuria, resulting in the Birth of a Dead Child, treated
with success in a Subsequent Pregnancy.

By Robert Wise, M.D.

Mrs. M., married, aged 29, multipara, a slightly stout and lethargic lady,
gave birth to a dead child during the eighth month of the first pregnancy,
having previously suffered from polyuria, thirst, weakness, and loss of flesh.

She had the following symptoms during the second pregnancy : Slight
nausea and vomiting, syncopal attacks, weakness, intense general pruritus,
marked polyuria, and vary great thirst. She used to rise seven or eight times
every night to micturate, and each time drank a large tumbler full of water.
She rarely drank less than half a gallon of water daily, besides other fluids.
She took no alcoholic drinks. She was often very drowsy, but had no coma.

The urine was usually pale, acid, with deposit of mucus ; no urates, no
albumin or blood ; specific gravity 1045, rising to 1050. It had a sweet odour,
and on being heated deposited burnt sugar. It quickly gave a brilliant yellow,
turning into a brick-red colour on boiling with Fehling’s solution, and usually
contained 10 to 15 per cent, of glucose.

Prognosis was varied, and very bad during the eighth month of her
pregnancy.

Treatment was by diet and drugs. At first sugar was stopped in her diet for
one week, but there was no improvement in her symptoms, nor any decrease
of the sugar in her urine. The withdrawal of all starchy food reduced the
specific gravity of her urine 5° in two days. Her diet was altered, at intervals,
to suit the condition present. Sugar, milk and potatoes were given, along with

i Proceedings , 1922, xv (Sect. Obst. and Gyn.), pp. 66-70.

36 Wise: Glycosuria; White: Instruments in Peritoneal Cavity

large doses of soda bicarb, and mix vomica, when diacefcic acid was found in
the urine, and when great drowsiness existed. Coma never occurred. She had
many prescriptions, but very few drugs, amongst which were pil. hydrarg.,
saline aperients, ammonium bromid., and magnesium carb., which cured
the sickness ; salicylates, potassium tartrate, Glauber’s salts, soda and nux
vomica, &c. She had no endocrine treatment.

The foetal heart varied in rate and sound, and also the foetal movements,
according to the condition of the mother; and the study of this relation led me
to understand better the cause of death of the first child in her previous
pregnancy.

Result .—She gradually improved, and by the beginning of the ninth month
her symptoms had all disappeared and very little sugar was left in her urine.
About ten days before her delivery, she told me that “ her womb had dropped,”
and examination showed the head of the child in the pelvis, and the urine, for
the first time, was free from sugar, the specific gravity being 1015. The rapid
change in the urine during the last week of treatment, coincident with dropping
of the child’s head into the pelvis, suggested a possible relief of some pressure,
perhaps releasing some intestinal villi for their absorption work, or allowing
more pancreatic secretion to pass in some cases.

The child was delivered at full time, alive, and weighing 9k lb. Mother and
child were both well a short time ago. The urine of the mother was free
from sugar.

Instruments left in the Peritoneal Cavity ; The Effects and
Results of this Accident as shown by an Analysis of
Forty-four hitherto Unpublished Cases.

By Clifford White, F.R.C.S.

My interest in cases in which solid objects have been unintentionally left
in the peritoneal cavity was aroused by having on two occasions to operate for
their removal. I may state that in both these cases the solid body in question
had been inserted into the abdomen by someone else, and that, to the best of
my knowledge, I have never yet left an instrument in a patient’s peritoneal
cavity.

The notes of the two cases mentioned are the following:—

(1) Spontaneous Partial FxtrtLsion of a Pair of Haemostatic Forceps from the
Peritoneal Cavity through the Cervix .—A patient, aged 50, was sent to me because
her doctor had found a sharp foreign body in the canal of the cervix. She had
consulted him on account of constant pelvic pain. The history given was that
nineteen years before she had had a laparotomy performed in the country for a
“ tumour,” but no details could be obtained. Seven years after this she was delivered
of a full-time child without difficulty, and had had moderate health, except for one
attack of severe abdomino-pelvic pain which subsided under treatment with hot
fomentations. The abdominal pain, with nausea and vomiting, gradually increased
in severity for several years, and for these symptoms she had had a second operation
performed upon her in a county hospital eighteen months before I saw her. She was
informed that the adhesions in the lower abdomen were so dense that nothing could be
done, therefore the operation was abandoned and the abdomen closed. The pain and
sickness increased and six months later an offensive vaginal discharge commenced.
The bowels were relaxed, with frequent desire to defiecatc, and there was frequency of
micturition.

Section of Obstetrics and Gynaecology

When I first saw the patient she looked toxaemic and wasted. The abdomen was
distended and there was a tender mass below, and to the left of, the umbilicus. There
was a hernia of the old laparotomy scar. On vaginal examination, a pointed metallic
instrument could be felt protruding through the cervix for 4 cm. from the external os.
The body of the uterus was bulky, and situated in the middle line. There was a mass
on the left of the uterus and above it, continuous with the tender area on the abdominal
wall. The X-ray photograph showed a Spencer Wells haemostatic forceps, with the
handles towards the left iliac fossa and the points in the cavity of the pelvis. It was
obvious that any attempt to remove it by traction on the pointed end would lacerate
the uterus severely, and possibly also damage the ureters. I therefore opened the
abdomen, and was faced by a mass of very dense adhesions. With difficulty I reached
the forceps ; the points had eroded the uterus 5 mm. above the level of the bladder
reflection; the handles had eroded the wall of the pelvic colon, and were lying inside
the lumen of the gut. The forceps was removed, and a pan-hysterectomy performed,
in order to get rid of the infected uterus, and to give free drainage to the faeculent
abscess in which the forceps was lying. Owing to the large deficiency in the gut wall,
and the infiltration of the surrounding tissues, it was difficult to suture the hole in the
colon, but finally the edges were united, and it was not thought necessary to do a
colotomy. Large drainage tubes were inserted through the vagina, and through the
abdominal incision.

The patient stood the operation well, but a faecal fistula formed at the end of a
week, and was still discharging six weeks later. She then began to suffer from peculiar
attacks of collapse with cyanosis, loss of consciousness, and vomiting. The first attack
came on after eating eggs, which had been sent to the hospital, and she stated that she
had never been able to eat eggs, as they had previously affected her in a similar
manner. It was suggested that the attacks were anaphylactic in origin. In one of
these attacks the patient died some six weeks after the operation.

The specimen shows a uterus 11 cm. long. Perforating the peritoneal covering
of its left anterior surface, is the pointed end of a Spencer Wells forceps, which
emerges into the canal of the cervix and then protrudes 4 cm. into the vagina. The
whole forceps measures 11 crn. in length and is of the usual pattern now in use.

This case is a rare one, because of the extrusion of the forceps through a tough,
thick-walled organ like the uterus. I have found no record of any other case in which
this happened. It is also uncommon because of the long period that the foreign body
remained in the peritoneum. It must have been left there either one and a half or
nineteen years before, and the longer time is suggested by the history that the pain
jpersisted and increased ifter the first operation, and was unchanged by the second.
The existence of adhesions so dense at the second operation that it had soon to be
abandoned also suggests that the inflammatory focus was already there. Also,
supposing the forceps to have been left in at the second operation, it should have been
finally found above the adhesions that the second operator did not separate, and not
low down. It is a question that cannot be settled, but it seems probable that the
instrument remained in the peritoneum for nineteen years.

(2) Removal of a Bone Penholder from the Epigastric Region .—This foreign body,
which had been passed into the vagina by a patient who was unable to withdraw it,
remained in the peritoneal cavity from 8 a.m. on January 2, 1915, till 4 p.m. on
•January 5, 1915. Even under anaesthesia no scar could be seen in the vaginal vault,
or on the fundus of the uterus, when the abdomen was opened. The penholder,
with the ink stains still showing well, was found entirely wrapped up in omentum.
I ligatured off the omentum containing the penholder, and closed the abdomen. The
patient made an uninterrupted recovery.

In discussing these two cases with my colleagues, I found that few of them
had had any experience of this accident, nor could I find much written about
it except one very valuable article by Crossen, and the records of a few cases
that had been published because they had given rise to legal proceedings.

In considering a question like the present, where negligence on someone’s

38 White: Instruments left in the Peritoneal Cavity

part comes in, it is obvious that the great majority of cases that are not the
subject of legal action will never find their way into the literature at all.
To get details of the unpublished cases, I sent inquiries to surgeons in all parts
of Great Britain. No names were asked for, but in order to obtain full,
although anonymous, records, I posted printed inquiry forms with printed
reply envelopes.

I wished primarily to find out what risk there is to a patient if an instru¬
ment is allowed to remain, say five or six days, in the peritoneal cavity. Such
a question may be of importance {a) if the loss of the instrument is not noted
till the patient has recovered consciousness ; ( b) if already suffering from such
a degree of shock from the operation that undoing the laparotomy incision may
be attended by grave risk; and (c) if it is desired to confirm the diagnosis and
locate the instrument by radiography before proceeding to open up the incision.
Secondly, after about what interval of time does the foreign body usually com¬
mence to cause symptoms, if its loss is not noted ? Thirdly, what is its usual
effect on surrounding viscera ?

Crossen 1 gives a short tabular summary of fifty cases that he collected from
the literature from 1880 to 1907. In these fifty cases the articles left behind
were: Forceps, forty-one; drainage tubes, three; finger-rings, two; N61aton
catheter, glass irrigator, scissors, “ piece of instrument/* and pair of spectacles,
one each. The total of fifty-one instruments in fifty cases is explained by two
pairs of haemostatic forceps being left in one patient by Kosinski.

Many of the cases abstracted by Crossen are incomplete, and essential
details are lacking, but an examination of his collected cases shows that some
twenty-four certainly, or probably, lived, thirteen died, and in thirteen cases
the details are inconclusive. The time in the peritoneal cavity in the cases
that recovered varied from a few hours to ten and a half years, but it is of
interest that in only seven out of twenty-four was the period over one year.
The foreign body was removed by a subsequent laparotomy in ten cases ;
removed through a sinus or abscess in seven cases : passed spontaneously per
rectum in four cases; removed by colpotomy in two cases, and once was found
in the bladder. In four of the non-fatal cases and two others it is stated that
serious damage resulted to surrounding viscera.

New Cases.

Including a few cases in which foreign bodies had been passed into the peri¬
toneal cavity either per vaginam or per rectum , I received details of thirty-
nine cases; there are three specimens bearing on the subject in the Museum
of the Royal College of Surgeons, making forty-four with the two cases
recorded in detail above ( see tabulated analysis, pp. 40-42).

The foreign bodies found were twenty-nine artery forceps, two retractor
blades, two glass rods, two bone knitting-needles, two hairpins, and drainage
tube, towel clip, uterine dilator, piece of needle, pin, bone penholder and
stone, one each.

Of the forty-four patients, eleven died, giving a mortality of 25 per cent.
In these eleven fatal cases the foreign body is stated to have been present:
several years, three cases; seven years, one case ; two years, one case ; one
year, one case ; five months, one case; three weeks, one case ; and twice
“ unknown.” In all cases, except those where the details are wanting,,
severe ulceration or erosion of the surrounding viscera was present.

i A tntr. Jaunt. Obstet., 1009, lix, pp. 58, 250: and also “ Operative Gynaecology,'’ 1915, p.589.

Section of Obstetrics and Gynaecology

Of the thirty-three patients who recovered, cases are given in which the
foreign body remained in the peritoneal cavity seven, twelve, fifteen and (?) nine¬
teen years. Of these thirty-three cases, twenty-six were treated by a second
operation, and in the remaining seven the instrument was passed through a
sinus, or per rectum . The operation was performed within a few hours,
five cases; within forty-eight hours, four cases; within a few weeks, eight
cases ; and the remaining nine during periods ranging from six months to
many years.

A consideration of the details of the cases seems to show that, as would be
expected, the best result is obtained by an immediate removal of the foreign
body, if the patient’s general condition permits of a second operation. But if
the loss of the instrument is not noted at once, or if the patient’s general con¬
dition contra-indicates an immediate second operation, there does not seem to
be any grave risk in leaving it inside for a few days. A solid metal instru¬
ment does not seem to cause the onset of peritonitis as rapidly as a
blood-soaked gauze sponge, and a consideration of the cases does not
indicate that the viscera suffer any severe damage within a few days.

A striking fact is the protective action of the omentum in surrounding the
foreign body and shutting it off from the rest of the peritoneal cavity. This is
well shown in the second specimen exhibited to-night.

The frequency with which this accident occurs came as a suprise to me. I
received details of thirty-nine fresh cases by post, and fifty-one forms were not
returned to me at all, in spite of the fact that I especially asked for the form
to be returned with a negative on it and sent a stamped addressed envelope to
ensure it remaining anonymous.

It seems reasonable to think that a large proportion of those fifty-one un¬
returned forms must have given details of fresh cases if their recipients had
returned them at all. Again, it should be noted that only surgeons on the
larger hospitals were circularized, and if the records of cases operated on in
cottage hospitals, naval and military hospitals, &c., could be obtained, it is
probable that my numbers would be again largely increased.

Most of the cases in which any date was given occurred within the last
fifteen years, so that my inquiries show that, quite roughly, at least forty of
these accidents have occurred in one hundred and eight months, or, in other
words, once in every four and a half months a patient is exposed to this
unnecessary risk in Great Britain alone.

It is therefore desirable to consider what can be done to diminish the risk
of this accident.

I have deliberately avoided so far all reference to sponges and swabs, and
definitely asked that these should not be included in my inquiry form. But it
is worth while emphasizing the protection given by the use of six or twelve
yard rolls of gauze for packing off intestines and sponging, instead of using
large numbers of small pieces of gauze. In counting a large number of swabs
by an assistant or nurse, the usual margin of human error exists, and this can
be avoided and time saved by the use of rolls of gauze as continuous
sponges.

Regarding instruments, the same principle can be applied and the numbers
of instruments in use, especially of Spencer Wells forceps, reduced to a
minimum, an extra supply in a separate package being kept in the operator’s
bag for emergencies. Also any instrument brought near the abdomen while
the peritoneum is open should measure 6 in. in length—an exception to this
rule must be made in the case of needles.

Analysis or Forty-four hithkrto I'nitblishkh Casks of Instruments left in the Peritoneal Cavity.

White: Instruments left in the Peritoneal Cavity

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Analysis of Forty-four hitherto Unpublished Cases of Instruments left in the Peritoneal Cavity.

White: Instruments left in the Peritoneal Cavity

Section of Obstetrics and Gynaecology

To conform as far as possible with the ideal I never use towel clips—it
is quite easy to fix all towels by two stitches, one at the pubes and one at
the upper end of the incision. Again, it is quite easy to fix efficiently the
rubber sheeting, towel, or whatever is used to protect the edges of the abdominal
wall by pieces of sheet lead, 3 in. broad and 12 in. long, which can be bent
round the edge of the wound. This method has long been used by Oldfield
and other members of the Leeds school. The use of a Reverdin needle not
only saves time but largely reduces the number of small needles in use. A
Reverdin needle of suitable shape can be used satisfactorily except at the
bottom of a deep wound.

In the Trendelenburg position, instruments tend to roll down towards the
incision, and the use of an instrument tray (such as that suggested by Bonney)
with a large flange will prevent this.

While operating, all haemostatic forceps should be replaced by ligatures
as soon as possible, instead of their being left hanging on to the bleeding
points at the edges of the wound or within the peritoneal cavity.

The use of any instrument that has loose parts that are liable to
become detached should be avoided.

DISCUSSION.

Mr. Arthur Giles said that one of the cases quoted in the table had occurred in
bis (Mr. Giles's) own practice though he was not responsible for the foreign body. It
was the case in which a pin was found embedded in the right broad ligament. It was
discovered in the course of doing an ovariotomy. He could only suppose that the patient
at some time must have swallowed the pin, and that this worked its way out through the
bowel wall. The important practical side of the paper was the question as to how surgeons
in the future could guard against such an accident as leaving an instrument in the
abdomen. In his opinion the two principal points were that as few instruments should
be used as possible, instead of the formidable array which some surgeons seemed to like
to see displayed; and that operations should be done in such an orderly and methodical
manner that the surgeon should know what his instruments were doing. As the
question of swabs had been mentioned in the paper, he might say that the use of
long rolls of gauze did not appeal to him at all. The gauze quickly worked up
into strings which failed complete^ in the essential purpose of keeping the bowel out
of the way. He preferred a large gauze and Gamgee pad, 10 by 12 in. square, sewn
round the edges. Only by gross carelessness could such a pad be overlooked. Further,
be considered that the plan long in use at the Chelsea Hospital for Women reduced the
chances of error in the counting of swabs to its minimum. Only two large swabs and
'ix or eight smaller ones, about 6 in. square, were put out. When a swab had been
u<ed it was placed in a bowl of sterilized water and washed out and used again. The
sole duty of the ward sister was the charge of the washing of the swabs. In other
hospitals he had seen operations at which eight, ten, or twelve dozen small swabs were
used : this method enormously increased the chances of a miscount.

Dr. H. Russell Andrews said that his own experience was limited to one case in
which first a celluloid bougie and later a metal dilator were pushed through the wall of
the uterus in attempts to induce abortion. Dr. Andrews had removed the bougie
t!irough a small incision in the posterior fornix, and, after an X-ray photograph,
removed the metal dilator, 8.J in. long, through a median abdominal incision about
1 in. long. The upper end lay just below the liver. The patient, who was not pregnant,
h id suffered no inconvenience from the presence of the foreign bodies, and made an
uninterrupted recovery. The bougie had been in the abdomen for six weeks; the
metal dilator for two or three days. The original operator said that he had not worried
about the bougie as he 44 thought that it would be absorbed,” but. after a thorough
v uoh under the bed had convinced him that the metal dilator had not fallen on the

44 White : Instruments left in the Peritoneal Cavity

floor, he was considerably alarmed, as he felt sure that the dilator was inside the uterus
which he considered to be three months pregnant. Though this was the only case in
which he (Dr. Andrews) knew of instruments being left in the abdominal cavity he
could relate a case in which disaster occurred from a still more unexpected accident—
viz., a tumour being left in the abdomen after separation of all its attachments. He
saw only the beginning of the operation, as he was interested in the diagnosis. An
operator of great experience opened the abdomen and showed Dr. Andrews a large
hydrosalpinx on each side. As the removal of these tumours did not seem to promise
anything of much interest he did not stay to see the operation completed. The patient
developed peritonitis and died. A post-mortem examination was performed and a large
necrotic hydrosalpinx was found loose in the abdomen, all the attachments having been
severed. He did not know what was the explanation—possibly sudden htemorrhage
made it necessary to pack off the intestines to expose the bleeding point and the
tumour was pushed out of the way and forgotten. It was extraordinary’ that neither
the operator nor his assistant noticed that only one trophy was to be seen after the
operation instead of two. This must be a very rare occurrence, otherwise it would be
necessary to add a new rule to the old one which warned the operator to count his
swabs and his pressure forceps—namely, “ count your tumours.”

Mr. Beckwith Whitehouse showed a specimen, consisting of half a bone knitting
needle, which was removed from a married woman who had introduced the same
through the uterine cavity for the purpose of procuring an abortion. The patient’s
history was as follows: The catamenia, previously regular, ceased in August, 1917.
Thinking that pregnancy had occurred she introduced a bone needle into the uterus
on October 26, 1917. Upon withdrawal of the instrument it wa-? noticed that half had
been retained. Considerable pain occurred and she consulted her medical attendant,
who explored the uterus at once and removed a two months’ pregnancy, but failed to
find any foreign body. No immediate complication occurred and the patient made a
sound recovery. The catamenia were resumed five weeks after the curetting. At the
end of December, 1918, the patient noticed abdominal pain, especially on bending,
and she was referred by her medical attendant for further examination. A radiograph
revealed the shadow of an elongated foreign body lying within the abdominal cavity.
Laparotomy was performed upon January 18, 1919, and the missing half of the needle
removed from the peritoneal cavity. The foreign body was completely enveloped by
omentum, but no wound of the viscera was noted. A scar was present at the fundus
of the uterus, marking the place of perforation. The patient made an uneventful
recovery.

Dr. L. MARTINDALE alluded to a patient of hers, a woman, aged 25, who seven
weeks ago had swallowed six needles, one pin, one hairpin, and part of a tortoise-shell
comb. She had operated last week and had found only one needle in the peritoneal
cavity, the others being in the stomach and jejunum (a gastro-jejunostomy had been
performed some years previously). As in Mr. Giles’s case there had been no actual
symptoms arising from the presence of these foreign bodies.

Mr. Eardley Holland said that for several years he had adopted the rule of
never using a short instrument in abdominal operations; the shortest instrument he
used was a dissecting forceps measuring 7 in. and his artery forceps, needle holder,
scissors and other instruments all measured 8-i in. or more. This did not ensure absolute
safety, but there was much less chance of leaving an instrument in the abdominal
cavity if it was of such length that one end would probably protrude from the wound.

Section of ©bstetrics anb <5pn#colOQ£

President—Dr. T. W. Eden.

A Necrotic Fibro-adenoma in a Patient, aged 74, simulating
Cancer of the Corpus Uteri.

Shown by J. S. Fairbairn, B.M.

This specimen shows a necrotic tumour attached to the inner surface of
the uterus, but distinct from it. It is a cystic fibro-adenoma and the vessels
in the uterine wall are distinctly degenerated. The reason for its being shown
is because of its clinical interest; it was removed from a mulfcipara, aged 74,
who gave a history of slight uterine haemorrhage with offensive discharge for
two months. She was stout with a very thick abdominal wall, which made
bimanual examination difficult. The cervix was small and atrophic and
showed no sign of disease, but the uterus appeared to be somewhat enlarged.
She was not a favourable patient for a radical abdominal operation, and before
removing the uterus it was decided to explore the cavity and only perform
hysterectomy if the condition was clearly malignant. Portions of necrotic
material came away as the dilators were withdrawn, and this appeared to be
sufficiently certain evidence of malignancy to make it unnecessary to go any
further; the cervical canal was, therefore, sewn up and the uterus removed
per abdomen. On examination of the specimen it is perfectly clear that the
tumour could have been removed per vaqinam , and the innocent nature of the
growth shows that this would have been quite satisfactory. It is polypoid
and could have been easily detached from the uterine wall by the finger. The
section under the microscope shows the growth to be made up of cystic
spaces lined by endometrial glandular tissue with a little fibrous tissue.
Professor Dudgeon described it as a cystic fibro-adenoma. A simple growth
of this type arising from an atrophic endometrium is outside my experience
and this specimen is brought before the Section in order to learn whether
others present have met with similar tumours at this age.

A Cyst of the Uterine Cornu due to Dilatation of the
Interstitial Portion of the Tube.

Shown by J. S. Fairbairn, B.M.

This specimen shows a cystic swelling in the right cornu of the uterus in
a patient, aged 42, who was operated upon for an inflamed ovarian cyst with
hoth Fallopian tubes distended with blood-stained fluid. An incision was
made into the cystic swelling in the cornu, which was about the size of a

Ar— Ob 1 [February 1, 1993,

46 Fairbairn: Cyst of Cornu; Wkitehouse: Adenomatosis Vaginae

walnut, as it was thought to be a soft fibromyoma which could be enucleated,
but fluid similar to that contained in the tubes escaped. The body of the
uterus was removed as the nature of the cyst was uncertain and at the time
it was thought to be of adenomyomatous origin ; on subsequent examination
it proved to be a distension of the tube within the uterine wall. Dr. Dyke,
Pathologist to the Surgical Unit of St. Thomas’s Hospital, kindly examined the
specimen and, as the slides under the microscope show, reported that the wall
of the cyst in the uterus had a mucous membrane similar to that in the tube,
from which it seems to have arisen by blocking up of the lumen by inflam¬
mation. Sections of the wall of the tube show chronic inflammation with
hasmorrhage into its tissues. This condition is one I have never met with
before and I have brought it forward in order to ascertain if others have seen
anything like it.

DISCUSSION.

Dr. Herbert Spencer said he had on one occasion diagnosed cancer of the body
in an elderly patient with a foul and hremorrhagic discharge. It was operated on by
another gynaecologist through the cervix and found to be a sloughing fibroid. Dr.
Fairbaim’s case of adeno-fibroma resembled one shown by the late Dr. Maxwell as a
case of cancer of the body.

Dr. T. W. Eden (President) said that he thought a fibro-adenomatous growth of
the endometrium so large as the specimen shown by Dr. Fairbairn was very uncommon.
Incidentally the case illustrated the fact that benign uterine tumours were a source of
danger even in advanced age, from the risk of necrotic changes followed by sloughing.
He thought that this case, illustrated by the second specimen show'n by Dr. Fairbairn,
was almost unique; he could not recollect having seen or read of a cyst formed from
dilatation of the interstitial portion of the tube.

Adenomatosis Vaginas.

By Beckwith Whitehouse. M.S.

The patient from whom the specimens were obtained was a 2-para, aged
40, who was referred to me on November 27,1922, by Dr. Dick, of Alvechurch,
Worcestershire. She gave a history of constant muco-purulent vaginal discharge
of some years’ duration, and unrelieved by the usual methods of vaginal
douching, tamponage and various applications to the cervix uteri. The last
pregnancy had been terminated by forceps five years previously and the dis¬
charge had gradually increased from this date. Throughout the year 1922 it
had been particularly troublesome and the patient was willing to submit to
any treatment for its relief.

Examination showed a very unusual condition of the vaginal vault. The
cervix was deeply lacerated, fibrosed and everted. It was the seat of numerous
small cysts of the typical Nabothian type. The interesting feature of the case,
however, was the extension of the cystic condition to the upper half of the
vagina. Both anterior and posterior walls of the vagina were completely
studded with small cysts varying in size from that of a pin’s head to that of
a small pea. The right vaginal fornix was packed with these cysts and they
extended on the right side of the vagina in a chain almost to the vulva.
Some of the cysts appeared translucent and resembled sago granules. Others

Section of Obstetrics and Gynaecology

occupied a subepifchelial position and could only be palpated as nodules. A
few in proximity to the cervix were involved in granulation tissue, but in
general terms the vaginal epithelium appeared to be healthy and intact,
without any inflammatory reaction. A considerable amount of mucopurulent
discharge occupied the upper fourth of the vagina but this appeared to be
chiefly cervical in origin.

The clinical appearance resembled the condition described and figured by
Bonney and Glendinning 1 as adenomatosis vaginae and this diagnosis was
made.

A further point of interest in the case is that the patient's uterus vvas
found to be of the bicornis unicollis type. This was not appreciated until an
examination under anaesthesia was made, when a sound passed easily into
each cornu.

Treatment .—The cervix was amputated by Schroeder’s method, several of
the vaginal cysts were excised for microscopical purposes and the remainder
as far as possible were obliterated by means of the cautery. Owing to the
number of cysts present this proved to be rather a tedious proceeding. The
vagina was subsequently packed with bismuth gauze.

A bacteriological examination of the cervical canal and vaginal discharge
failed to show any point of interest. So far it is too early to say anything
definite about the subsequent history. I am informed that up to date the
patient has reported herself to be comfortable and free from discharge.

As regards the pathology of the vaginal cysts, the first report received
stated that the cavities were lined by a single layer of flattened cells and that
the cysts were presumably lymphatic in origin. Apparently this report was
based upon an investigation of the larger cysts only. Subsequently a second
statement was made to the effect that the epithelial lining of the small cavities
was cubical and in places columnar. A similar appearance was seen in the
cysts present on the cervix, and this points to the fact that they are all pro¬
bably adenomatous in origin. The cysts are embedded in a fibrous matrix,
and with regard to the vaginal tissues no evidence of recent inflammation is
present.

The question naturally arises as to whether the condition is the result of
embryological or of inflammatory factors. The co-existence of a uterus
bicornis unicollis is evidence in favour of embryological agency. On the other
hand, the distribution, clinical history and similarity between the cervical and
vaginal conditions appear to point to an extension of chronic inflammatory
reaction from the cervix to the vagina. Small isolated cystic glands appear
to be not uncommon about the vaginal vault in association with chronic
inflammatory lesions of the cervix uteri. I have frequently met with them
under conditions calling for amputation or plastic repair of the latter. The
case here described appears to be a very exaggerated instance of the same, and
is reported as such, rather than as an example of displaced Wolflian or
Mullerian rudiments.

Dr. T. W. Eden (President) thought that the origin of these adenomatous growths
of the vaginal wall was a difficult point to decide. It might well be that they arose
from embryonic rests of Mullerian epithelium, and the occasional occurrence of simple
tubular glands in the vaginal wall which had been demonstrated by several observers
might be explained in the same way.

1 Proceedings , 1910-11, iv (Sect. Obst. and Gyn.), pp. 18-25.

48 White-Cooper and Griffith: Inversion of the Uterus

Inversion of the Uterus occurring in the Third Week of the

Puerperium.

By W. R. White-Cooper, M.B., B.S.Lond., and
H. K. Griffith, F.R.C.S.Eng.

The patient was a Mrs. K., aged 26, primipara, under the care of
W. R. W.-C. Full time labour began on March 14, 1922, the contractions
being slow and scarcely painful. At the end of ten hours the head was in the
pelvis, position R.O.A., the vertex presenting and the os fully dilated. Three
hours later the head had descended on to the perineum, but the pains were
few and hardly felt, and the patient was spending the time playing cards.
After several hours waiting the pains did not become any stronger, so 0’5 c.c.
of pituitary extract was given subcutaneously. Chloroform anaesthesia was
induced, and the forceps applied, and with one good pain the child was born
alive.

One hour later there had been only a few feeble uterine contractions, so half
a drachm of extract ergot liq. was given by mouth, and a further 0*5 c.c. of
pituitary extract given subcutaneously. Later the placenta was found in the
vagina with the membranes still adherent; the membranes were peeled off
intact and the uterus massaged. There was severe post-partum haemorrhage
controlled by bimanual compression of the uterus and hot douches. The
patient was collapsed and practically pulseless, but slowly rallied under the
administration of rectal salines, hypodermic injections of strychnine and
Curschmann’s solution. The perineum, which had been torn back into the
rectum, was sutured.

During the next fourteen days the patient slowly improved in general con¬
dition but remained very anaemic, and the uterus contracted down slowly.
The temperature varied between 99° F. and 101° F., the pulse-rate from
96 to 118. The lochia were offensive, but ceased to be blood-stained about
the tenth day.

On March 26 when the sutures were removed from the perineum the wound
fell open, showing no signs of attempt at union. On vaginal examination it
was noticed that both the external and internal os were dilated and
patulous. There was a uterine discharge, small in amount and slightly
offensive.

On March 29 the patient sneezed several times, and this was followed
by bright haemorrhage from the vagina, about 2 to4oz. in amount. Very slight
haemorrhage occurred on one or two occasions subsequently. Three days
later she had a rigor in which the temperature rose to 105*2° F. and the pulse-
rate to 140; 20 c.c. of polyvalent streptococcal serum were then given. On
the next day she had two more rigors. When seen at 6 p.m. by H. K. G. the
patient looked very ill and anxious. There was marked anaamia, the tempera¬
ture was 101° F., the pulse 130, volume poor. Nothing abnormal was
discovered in the chest. The abdomen was retracted with slight tenderness
over the lower third, the uterus not being palpable. Per vaginam the perineum
was completely torn into the rectum, with no signs of any attempt at granula¬
tion on the raw surfaces. The cervix was widely dilated, and protruding
through it was a smooth round tumour, about 4£ in. in diameter, which bled
easily on touch. Bimanually the body of the uterus could not be identified

Section of Obsteti'ics and Gynaecology

above the cervix, and in place of it a dimple could be felt. The diagnosis was
thus made of inversion of the uterus with possibly septiceemia.

Under a general anaesthetic a hot vaginal douche was given, and the body
of the uterus grasped and slowly compressed, so that after about five minutes
it began to re-invert, the fundus slipping back quickly through the cervix. Hot
intra-uterine douches were given, but in spite of this the uterine wall remained
flabby, and was dented in by the pressure of the intestines above, so the cavity
was packed with gauze soaked in flavine. The perineum and rectum were
rapidly sutured with two layers of catgut and silkworm gut, the sphincter
being left unsutured ; 500 c.c. of gum saline were given intravenously at the end
of the operation. She had a rigor, the temperature rising to 106° F., on coming
round from the anaesthetic. No pituitary extract or ergot were given owing to
fear of irregular uterine contraction. The patient had no after-pains ; the
plugging was slowly withdrawn, beginning twenty-four hours after the opera¬
tion, and it was completely removed by the end of the third day. It was very
offensive. During the first three days the patient had several rigors, the
highest temperature being 106*2° F. and pulse 120.

Other treatment consisted in daily subcutaneous injections of cacodylate of
iron and strychnine and 20 c.c. of polyvalent streptococcal serum and douches.
The patient's condition slowly improved, the rigors gradually diminishing in
severity and frequency, but at the end of a week thrombosis of the right leg
took place. At the end of the second week the catgut in the perineum gave
way and the whole wound gaped, showing no attempt at healing. At the end
of three months the patient was convalescent and able to get up. She has
since resumed her work as a school teacher, and apparently suffers from no
inconvenience from the torn sphincter and perineum.

The interest in the case lies in the peculiar inertia of the uterus which was
present throughout the first stage of labour ; it practically caused no incon¬
venience to the patient, but it almost completely prevented further progress-
After the child’s birth there was very poor power of retraction, and this
resulted in the inversion, which possibly began with the patient’s sneezing
attack. The intense anaemia undoubtedly assisted in the subinvolution
as well.

DISCUSSION.

Dr. Herbert Spencer referred to his paper read before the Section on nine cases
of inversion of the uterus, 1 in which he had pointed out the danger, which the late Dr.
Maxwell had emphasized, of replacing a septic inverted uterus, and the advantages of
irrigation before reducing the inversion with Aveling’s repositor. He thought it was
futile and dangerous to stitch up a torn perineum in the presence of a septic condition
of the parts.

Dr. J. D. Barkis congratulated the authors on the successful termination of an
extremely serious and anxious case. He said that Dr. Donaldson and himself had reported
before this Section (November 4, 1920), 2 a case somewhat similar from the fact that the
inversion occurred apparently a considerable time after labour, and w r as complicated by
sepsis. The patient, aged 24, was in her third labour, which was managed by a mid¬
wife. Labour w*as uncomplicated until the expulsion of the placenta, which w r as delayed
for more than tw r o hours, and after that time the midwife delivered it by pressure on the
abdomen and traction on the cord ; the patient then became collapsed and bled freely.
On her admission to hospital she was in a condition of shock. The fundus could be

1 Proceedings, 1919-20, xiii (Sect. Obat. and Gym), pp. 20-37.

2 Proceedings , 1920-21, xiv (Sect. Obst. and Gyn.), p. 207.

Cameron: The Technique of Caesarean Section

felt protruding slightly through the cervix. She was treated first for shock and haemor¬
rhage by blood transfusion. It was decided to delay reposition of the fundus; Sepsis
was evident by the third day of the puerperium, but was controlled by means of con¬
tinuous irrigation through Carrel’s tubes. On the sixth day of the puerperium, while
the patient was micturating, the fundus became completely inverted. He (Dr. Barris)
would make two comments upon the case just reported. The first was with regard to
the time at which the inversion occurred. He gathered that in the opinion of the
authors the inversion did not take place until the fourteenth day of the puerperium.
He thought it more probable that it really began immediately after labour, for the
placenta was manually removed and they found the membranes adherent at a time
when they also noticed that the uterus was relaxed. Moreover, in his own case,
although the inversion became complete on the sixth day, it had been noted on
admission that it had already really begun. His second comment was with regard to
immediate replacement of the fundus. Shortly before his own case occurred he had
heard Dr. Spencer’s paper. Late reposition was tried partly for this reason, and also
not to subject the patient to the shock of manipulations and an anaesthetic. He found
that the uterus involuted well, and did not bleed while still inverted. Reposition was
not carried out until seven weeks after the delivery. The fundus was replaced by
means of Aveling’s repositor without anaesthesia in nineteen hours, and the repositor
was removed easily at the end of this time after five minutes* further traction. He
wished to endorse Dr. Spencer’s remarks on this point, and to emphasize the safety
and value of late reposition as opposed to immediate replacement of the inverted
fundus.

Dr. W. R. White-Cooper and Mr. H. K. Griffith also read a short
communication on “ A Case of Obstructed Labour.”

The Technique of Caesarean Section.

By Samuel J. Cameron, M.B.

My object in making this communication is to relate briefly the technique
which has enabled me in 107 successive cases of Caesarean section in rachitic
subjects to bring the mortality in my practice to under 1 per cent., and also to
record a few observations which have interested me in connexion with the
operation.

Although many of the patients in the series were admitted to hospital in
labour, it is a decided advantage to have the patients under observation for
some days before the operation takes place, as minor ailments can be treated
and thorough preparations can be made. For example, special attention should
be given to patients with “colds,” as it has been my experience that rachitic
patients are peculiarly susceptible to pulmonary complications after operation,
and it will be found that many of them are troubled with chronic bronchitis
and emphysema. Consequently the choice of an anaesthetic seems to me to be
important. Chloroform should be used in preference to ether as the chloro¬
form has a less chilling effect on the lung; (in my gynaecological practice I
generally employ ether). Precautions should also be taken to guard against
exposure. I have frequently seen patients kept naked on the table for many
minutes after the completion of the operation, while nurses with lotions were
assiduously removing every trace of staining from the skin. As soon as I have
secured the anchor sutures which retain the dressing, the patient is wrapped up
and her head covered with a blanket while she is being removed to a warm
room.

Section of Obstetrics and Gynaecology

The patient in the one fatal case in my series died from broncho-pneumonia
ten days after operation; ether alone was administered during the section, and
since then I have always used chloroform. So far I have not tried spinal
anaesthesia and gas in CaBsarean section, but it is doubtful whether this method
of anaesthesia will lessen the incidence of bronchitis. Whenever bronchitis
proves troublesome after operation I immediately place the patient in a tent
with a steam kettle. Invariably she experiences great relief and in cases in
which the heart exhibits signs of flagging camphor in oil proves an effective
stimulant.

The next danger to be considered is the important one of sepsis. At the
outset of my surgical career I performed Caesarean section even when the
membranes had been ruptured for many hours, and the fact that the forceps
had been applied by the practitioner did not deter me. As a rule the patients
recovered, but a few died and others had a prolonged convalescence due to
septic infection. The loss of life was regrettable and accordingly I determined
to operate only in cases which were presumably free from contamination. I
therefore now perform craniotomy in most cases in which the patients have
been repeatedly subjected to vaginal examinations before admission to hospital,
and in all such cases if the membranes have been ruptured for longer than
twelve hours. Even if a patient had not been examined vaginally I found that
the mortality was great if labour had been allowed to proceed until exhaustion
occurred after rupture of the membranes. Cases of this description I now
treat by craniotomy instead of Caesarean section. Other important factors in
the elimination of sepsis will be mentioned as I describe the operative
technique which I adopt.

For many years I have operated on my gynaecological cases either
through an incision in the rectus sheath or through a transverse wound.
Within recent years I have adopted the incision through the rectus sheath in
cases of Caesarean section owing to the fact that a weak wound is liable to be
obtained by a middle line incision as the abdominal wall in this situation is
attenuated by the large gravid uterus. Since I adopted this incision ventral
hernia has been abolished from my obstetrical practice. Owing to stretching
of muscle and fascia the wound should be made at a considerable distance
from the middle line. It is a matter of some importance as to whether the
right or left side is chosen. The incision ought usually to be made on the
right side as the uterus almost always lies towards the right, and therefore the
left margin of the organ approaches the middle line of the abdomen. Some
time ago I was performing the operation in a country establishment where the
lighting equipment was miserable, and the uterus was exposed through an
incision in the left rectus sheath. As soon as the uterine incision was made
profuse haemorrhage occurred from the lower angle of the wound and it was
found that some large veins in the left broad ligament had been severed.
Difficulty was experienced in arresting the haemorrhage. The left border of the
uterus in this case was situated near the middle line, and if the incision had
been made on the right side of the abdomen the above unpleasant complica¬
tion would have been avoided.

Every surgeon who has had a large experience in dealing with cases of
repeated Caesarean section has probably been hampered on several occasions
by numerous and dense adhesions in the region of the former scar or scars.
The attachment of the uterus to the parietes can often be diagnosed before the
abdomen is opened, owing to movements communicated to the uterus being
accompanied by in-dragging of the abdominal wall. In consequence of the

Cameron: The Technique of Caesarean Section

intimate fusion which often exists between uterus, parietal peritoneum and
intestine, the operation may be dangerously prolonged if the usual technique
of dealing with adherent cases is followed. I have known an accomplished
obstetric surgeon lose a patient from shock after a tedious operation of this
description. In my opinion destruction of existing adhesions is inadvisable,
as their obliteration would probably be followed by the formation of fresh
bands and in some instances intestinal loops might adhere to a denuded
portion of the uterine surface which was formerly in contact with parietal
peritoneum.

In treating adherent cases I take this opportunity of strongly advocating
my practice of evacuating the uterine contents through transverse incisions in
the abdominal and uterine walls. By so doing the surgeon can avoid the
labyrinth of adhesions, and as the uterus is usually tightly fixed to the parietal
peritoneum the organ remains there in a state of ventro-suspension. It is
probable that the attachment of the uterus to the parietes favours incomplete
retraction, as on several occasions I have observed profuse post-partum haemor¬
rhage in these cases. Pituitary extract injected into the uterine tissue will
prevent this complication. As a rule I make the transverse incision a short
distance above the upper extremity of the old scar and this will usually be
situated above the level of the umbilicus and near the fundus of the uterus.
Upon the abdomen being opened, the free portion of uterine wall near the
fundus is severed transversely, and then the child and placenta are extracted.
By this procedure I avoid adhesions and the operation is almost as easily
performed as in an uncomplicated case.

Some obstetricians still omit to place gauze between the parietal peritoneum
and the uterus before the uterus is incised. This is a mistake, as blood and
liquor amnii obtain access to the peritoneal cavity. Should the case be
infected, such contamination may prove fatal. Before opening the uterus
I insert four large swabs, so that two are situated laterally and the other two
at the upper and lower angles of the abdominal wound. The swabs are not
removed until the wound in the uterine wall has been closed.

Some years ago it occurred to me that lives were lost owing to a single
knife being used throughout the operation. Many urgent cases of Caesarean
section are subjected to a hurried preparation and it seems to me that the
knife which severs an infected skin may carry organisms into the wall of
the gravid uterus with fatal consequences. Accordingly I altered my technique
and used two knives, one for the abdominal and the other for the uterine
wall. It may be merely a coincidence but nevertheless my results improved
immediately.

When the uterus has been opened I always deliver the child as a breech,
and as the limb is often greasy the nurse who is attending to the dressings
keeps a large swab in readiness to pass on to me to prevent the hand slipping
during extraction. Immediately the child is delivered the uterus should be
drawn through the parietal wound on to the abdominal wall. There the organ
should be turned inside out, so that the placenta and membranes can be
stripped from their attachment. For this purpose a large pledget of gauze
should be used. In most instances the membranes in the region of the cervix
are the most difficult to detach and it is highly desirable that they should be
entirely removed, as even a small portion overlying the os may prevent
the lochia from escaping for several days. From information supplied by
Dr. Murdoch Cameron and many of his former pupils and house surgeons
we may conclude that the extremely useful procedure of inverting the uterus

Section of Obstetrics and Gynaecology

was first practised by him, but he employed it only in cases where the
membranes were adherent to the lower segment. Gradually the practice
became an invariable one at the Glasgow Maternity as it ensured thorough
emptying of the cavity. When the extraction of the placenta and membranes
has been completed the inner wall is thrust back into position in order that the
uterine wound may be closed. Many years ago I accomplished this by means
of several mattress sutures and one continuous suture, but I have discarded
this method as I found that in some instances there was morbidity in the
puerperium. Doubtless this may have been due to excessive compression of
tissues by the mattress sutures. For this reason also, I never place mattress
sutures in the cervical stump after the operation of supravaginal hysterectomy,
as on one occasion, in which the patient was an anaemic woman, a suture of
this description caused localized necrosis. After abandoning the mattress
suture I inserted three interrupted sutures of silk: one suture was placed
in the middle of the wound and the other two midway between the first suture
and the upper and lower angles of the wound. Each suture passed through the
entire depth of the uterine wall, with the exception of the inner layer.
The remainder of the wound was closed with interrupted sutures of catgut.
Finally a continuous suture of catgut was used throughout the entire length of
the wound. The three sutures of silk were a safeguard in case the catgut
became absorbed too rapidly. Care was taken to cut the ends of the sutures
level with the surface of the uterus. A sinus did not develop in any case.
Despite the warning given by Mr. Eardley Holland in his valuable communi¬
cation 1 as to the dangers arising from the use of catgut, I sometimes rely
entirely on this material as when properly prepared it holds the tissues
in apposition as efficiently as silk, and moreover it has the advantage of
disappearing within three weeks. If union of the various elements has not
taken place by that time it never will. My experience has been that all
interrupted sutures lie loosely in tissues after a few days and so silk does not
keep the tissues more firmly lashed together than catgut. It seems to me that
the free use of silk within the abdomen is unjustifiable, as the presence of this
durable material may readily lead to the formation of dense adhesions, and,
moreover, it may be the cause of great misery if it becomes infected, as a
persistent sinus forms. This event is of common occurrence and on two
occasions patients were sent to me for the closure of uterine fistulae which
had resulted from infected silk sutures. Each month the unhappy women
menstruated on to the abdominal wall. This evening I also show you vesical
calculi, which originated from silk sutures in the uterus having made their way
through the wall of the bladder.

Adhesions within the abdomen are usually undesirable, but I have met
with cases of repeated Caesarean section in which their presence seemed
advantageous, since they caused firm fusion between the uterine scar and the
parietal peritoneum, thus diminishing the tendency to rupture. Despite
various modifications in the method of closing the uterine wound, the danger
of rupture in subsequent pregnancies still exists. Personally I have met with
four cases. From my observations on these cases I have come to the
following conclusions: The gravity of this complication depends to a great
extent on whether the uterus manages to expel its contents completely or not.
(1) If there he only partial extrusion from the cavity, the uterus cannot
retract effectively and death may rapidly ensue from haemorrhage. , (2) On the
other hand, if the entire contents are quickly ejected into hKe peritoneal

Procerdinqs, 1920-21, xiv (Sect. Obst. and Gy*'.), p. 46.

Cameron: The Technique of Caesarean Section

cavity, and if rupture be unaccompanied by severe shock, I believe that the
patient may actually walk into hospital and live for some days without
operation. In such instances little blood will be found in the belly cavity,
and the empty uterus remains in a state of firm retraction. (3) I am also of
opinion that in cases in which the uterine wound has been infected there
is less loss of blood when rupture occurs, as the margins of the wound have
never remained in apposition and the opposed surfaces are non-vascular.

Frank's procedure of opening the uterus in its lower segment has been
more extensively practised during recent years in Germany and America with
the object of abolishing rupture. Modifications of Frank’s technique have
been introduced from time to time, and the liability to rupture certainly seems
to have been diminished, but it should be remembered that the cervical
incision is seldom employed in comparison with that in the uterine body.
An additional advantage which appeals to me in the cervical operation is that
adhesions will be less apt to form. On the other band it is an operation for
the specialist rather than the general practitioner, and this view should not be
lost sight of as small maternity homes staffed by practitioners are being
opened in all parts of the country. During extraction of the head I have
known alarming haemorrhage result from extensive tearing of the tissues where
a transverse incision had been made. The transverse wound should also be
avoided because the muscular fibres in this area are for the most part arranged
longitudinally. Another objection to the low incision is that operation must
be delayed until the patient is well on in labour so as to permit sufficient
stretching of the lower segment.

Although compression and massage of the uterus between hot swabs is
often practised in the course of the Caesarean operation, this manoeuvre was
not adopted in any of the cases in this series.

As soon as the wound in the uterus is closed the four large swabs are
withdrawn and the abdominal incision is united in layers. For many years
I have used anchor sutures to support the wound and to keep the small gauze
dressing in position. No other covering is applied to the wound. Before the
patient leaves the operating table the surgeon should observe whether blood
is escaping from the vagina or not; if it is not he should grasp the uterus and
compress it through the abdominal wall. Should a trickle of blood fail to
appear, the probability is that a retained portion of membrane is occluding
the os. The external parts should therefore be bathed with an antiseptic
lotion and afterwards the vaginal walls should be swabbed with a similar
solution which is carried into the vagina on gauze attached to a sponge holder.
The gloved fingers are next passed into the vagina and the index finger is
forced up the cervical canal to break down the obstruction. In a few instances
the cervical canal may be so narrow and rigid that the cervix has to be seized
with volsella in order that a few Hegar’s dilators may be passed, but it is
almost unnecessary to state that the less frequently such manoeuvres are
required and adopted, the less likely will sepsis ensue. In my surgical practice
I have for many years allowed my patients every liberty of movement as soon
as they become conscious after the operation. They are encouraged to lie on
their side and sit upright in bed in Fowler’s position. By so doing drainage
is promoted, flatulence is diminished, convalescence is shortened and the
liability to thrombosis is lessened. In conclusion I may state that the only
otjho& .dentil, which I have had in my Caesarean sections in recent years
. > ’’-ob^ui'Ted.’* frw "jbaea which was complicated by pronounced toxaemia and

. V- "placenta praevia. *’*£>eajth was due to suppression of urine. My impression
is that Caesarean sectibriL should never be performed in toxaemia of pregnancy.

Section of Obstetrics and Gynaecology

A Note on Two Cases of Caesarean Section under Spinal
Anaesthesia with Tropacocaine.

By Beckwith Whitehouse, M.S., F.R.C.S., and
Henry Featherstone, M.B.

In March, 1914, Dr. J. D, Barris [5] recorded before this Section a successful
case of Caesarean section under spinal anaesthesia with stovaine, the indication
being pregnancy complicated by severe cardiac disease. The author of this
communication was able to collect records of three other instances in which
spinal anaesthesia had been used in this country for Caesarean section, by
Walls [4], Fairbaim and Stabb. The literature, however, both here and abroad,
is scanty and within the past ten years but five references directly bearing upon
the subject can be traced.

At a meeting of the Section of Anaesthetics on November 3, 1922, 1 in
which Members of this Section took part, the anaesthetization of patients for
classical Caesarean section was under discussion. Again but a brief reference
was made to spinal anaesthesia. Dr. Herbert Spencer, in his opening remarks,
stated that “ spinal anaesthesia is undoubtedly more dangerous than inhalation
anaesthesia, and has drawbacks from which inhalation is free.” Dr. Hadfield
had found, however, that “ in the half dozen or so cases in which he had used
spinal anaesthesia, the results had all been most satisfactory.”

Two instances recently occurred in the Obstetric Department of the
General Hospital, Birmingham, in which the Caesarean operation was per¬
formed under spinal anaesthesia with entirely favourable results. In fact,
certain advantages attached to this method so impressed us that we have
ventured to place the facts before this Section.

Case I.

A. F., a 2-para, aged 29, was admitted to the General Hospital on
October 11, 1922. She gave a past history of chronic nephritis, and each of
her previous pregnancies had been complicated by generalized oedema.
Pregnancy dated from about March 17, and its progress had been marked by
progressive wasting, headache, vomiting, oedema of the lower extremities, and
much pruritus and swelling of the vulva. The patient was much emaciated
on admission and the vulva presented the typical lesions of diabetic vulvitis.
The urine contained much albumin, numerous epithelial “ casts,” acetone,
diacetic acid and glucose, 1*3 per cent. The urinary diastase number was 10.

The patient was placed under the care of one of our medical colleagues,
Dr. A. P. Thomson, and at first under a rigid dietetic regime improvement was
noted, both in the general condition and also as shown by the renal function
tests. The glucose content of the blood, however, showed no improvement,
and on November 17 Dr. Thomson advised termination of the pregnancy.
The percentage of blood-sugar on this date was 0*2 per cent, one hour after
food.

Caesarean section was performed on November 18, the abdominal route
being selected owing to the risk of sepsis attached to induction; the vulva and
j>erineum being the seat of much solid oedema and furunculosis. Spinal

1 Ibid, 1922-23, xvi (Sect. pp. 1-1.

56 Whitehouse and Featherstone: Caesarean Section

anaesthesia was employed in order to avoid the possibility of degeneration of
the hepatic cells from inhalation narcosis. The operation taking place one
month before term, a further indication existed in the interests of the child.
Half an hour before operation a hypodermic injection of morphia & gr. was
administered. In the anaesthetic room the patient was turned on to her left
side and requested to flex her neck and her hips. This is a more convenient
position for these cases than the sitting posture. Barker’s spinal needle was
introduced between the second and third lumbar vertebrae, care being taken to
see by the flow of cerebro-spinal fluid that the spinal theca was actually
entered; 1*5 c.c. of a 5 per cent, solution of tropacocaine (Allen and Hanbury)
dissolved in normal saline solution was drawn into the syringe, and after about
10 c.c. of cerebro-spinal fluid had escaped from the needle the syringe was
connected and the piston withdrawn very slightly to ensure that the point of
the needle had not been inadvertently displaced. The contents of the syringe
were slowly injected, the needle withdrawn, and the puncture wound covered
with collodion. The patient was laid on her back with the head on a pillow
and the body inclined, shoulders slightly downwards. Full anaesthesia was
present in five minutes. A screen was interposed between the patient’s face
and the seat of operation, and steps were taken to cut off all visual and
auditory sensations. The operation was completed in twenty minutes and no
inhalation either of a narcotic or oxygen was required throughout.

^During the operation three points of interest call for special mention:—

(1) The Condition of the Child. —The infant was very vigorous, cried
lustily as soon as extracted, and presented a very different appearance from
that often seen when inhalation narcosis is employed.

(2) The Tone of the Uterus. —This was very evident from the moment of
incision into the organ and even before. As soon as the child was extracted
the uterus contracted firmly and partially expelled the placenta through the
uterine incision.

(3) The bloodlessness of the whole operation , owing, of course, to the
tone of the uterus. Only four dry abdominal mops were used throughout.

There was no vomiting, and the after-history of the case was uneventful.
The pulse-rate of the patient on leaving the theatre registered 104. Within half
an hour it fell to 80, and subsequently varied between this rate and 96.
Sensation returned slightly within one hour, and in two hours the patient
complained of abdominal pain. This apparently was never severe. No serious
haemorrhage occurred from the placental site, and both pituitrin and ergot were
withheld throughout for purposes of observation.

The following day some flatulent distension of the abdomen was present,
but this was relieved by the ordinary nursing measures. Urine was passed
naturally at the end of twenty-four hours after operation. The patient was
somewhat drowsy for the first few days, and slept a good part of each
twenty-four hours. By November 30, however, glucose had disappeared from
the urine, and only a trace of albumin was present. She was discharged to a
convalescent home on December 8, 1922, and we have been recently informed
that both she and her baby are in good health.

Case II.

K. L., a 2-para, aged 29, was admitted to the obstetric department of the
General Hospital, Birmingham, on November 9, 1922, complaining of ante¬
partum hemorrhage. There was doubt as to the exact period of pregnancy, as

Section of Obstetrics and Gynaecology

the patient’s last menstruation occurred at the beginning of May, 1922, and
on admission the size of her uterus corresponded to a gestation of seven
months. In June, haemorrhage occurrod with the passage of some clots, and,
with slight intermissions, bleeding had continued irregularly until the date of
admission to hospital. Periodical attacks of uterine pain from August onward
had suggested that premature labour might be imminent, but with the aid of
absolute rest and hypodermic injections of morphia the pregnancy continued.

On admission, the height of the fundus uteri above the pubes measured
12 in. The foetus occupied a right occipito-posterior position, and on vaginal
examination the lower uterine segment appeared to be filled with an inelastic
swelling. No foetal part could be palpated per vaginam. The foetal heart
was audible in the right lumbar region. A diagnosis of placenta praevia was
made, and the patient confined to bed until it was thought that the foetus was
viable. For reasons which need not be discussed on this occasion, delivery by
Caesarean section was decided upon. Further, in the interests of the premature
foetus, spinal anaesthesia was selected.

Operation : The operation was performed on December 21,1922, at 9.30 a.m.,
the same technique being employed as in the previous case. The spinal theca
was tapped, and 1’5 c.c. of a 5 per cent, solution of tropacocaine introduced
through the first lumbar space. Anaesthesia had extended to the middle of the
sternum in five minutes. The operation followed the usual lines and the
patient left the theatre under half an hour.

Before the operation the systolic blood-pressure was 98, and the diastolic
75 mm. Hg, with pulse-rate of 100. Upon the patient’s return to the ward
the systolic blood-pressure was still 98, the diastolic having fallen to 70 mm.
The pulse-rate was now only 88.

The patient herself was very much pleased at having the operation carried
out “without an anaesthetic,” as, in her own words, she “had been dreading
it so.” Apparently she did not object to the technique required by the spinal
method.

After the extraction of the child she expressed a desire for a drink, and
swallowed a cup of hot black coffee. As in the previous case, the baby showed
no signs of cyanosis, and progressed very satisfactorily from the moment of
birth. No artificial stimulation was required. Contraction of the uterus
was again a feature of the case, and made the actual operation almost
bloodless. Owing to the central position of the placenta over the os internum
and the rapid contraction and retraction of the uterus a slight difficulty was
met with in delivering the placenta.

The subsequent history of the patient differed but slightly from the first
case. Vomiting (2 oz.) occurred fifteen minutes after her taking the cup of
coffee, and again (4 oz.) after taking a cup of weak tea in the afternoon fol¬
lowing the operation. Apart from these occasions no vomiting took place.
Sensation returned at the end of one hour, and the presence of somewhat
severe abdominal pain called for an injection of morphia (i gr.). The lochia
were more profuse in this case than in the preceding, but were never alarming.
No pituitary extract was used, but ergot was administered hypodermically
four hours after operation and subsequently in mixture. The increased haemor¬
rhage occurred after the effect of the tropacocaine had passed off, and was
attributed to the low placental site. Urine was voided naturally five and a half
hours after anaesthesia. Flatulent abdominal distension was not a feature of
this case. The patient made a non-febrile convalescence, and was discharged
to a convalescent home on January 8, 1923.

58 Whitehouse and Featherstone: Caesarean Section

The two cases here recorded tend to confirm the previous observations of
Polano [l], Barris [5], Walls [4], Wyatt [3], Marsh L6] and others in proving
that Caesarean section under spinal anaesthesia is a safe and reliable proceeding
both to mother and child. Further, under certain conditions, e.g., morbus cordis,
diabetes, &c., it appears to offer special advantages to the mother over inhala¬
tion narcosis. As to the effect upon the child, in our experience there is no
comparison between the results of spinal and inhalation anaesthesia, however
little chloroform or ether are employed.

To effect a surgical degree of anaesthesia sufficient for the purpose of
abdominal Caesarean section, an amount of volatile narcotic must be absorbed
which may prove deleterious to a premature infant. In cases of Caesarean
section performed before “ term ” we venture to suggest, therefore, that spinal
anaesthesia may find an application in the interests of the child, without
increasing the mortality or morbidity of the mother.

Concerning the disadvantages of the method, they are those w'hich have
been put forward with regard to spinal anaesthesia in general, and are not
influenced by the more pressing obstetric indications. Certainly looking
through the small number of cases hitherto recorded, they appear to be more
theoretical than real. At the same time, until more experience has accu¬
mulated, we think that the method should be confined to institutional
practice.

In conclusion, may we draw attention once more to the increased tone of
the uterine muscle under spinal anaesthesia with tropacocaine ? In all the
recorded cases it is noted that the uterus contracted well, and certainly in both
our patients contraction and retraction were in excess of normal. What is the
cause of this phenomenon? In labour occurring in paralytics, as also in
bitches after experimental division or destruction of the lumbar cord, the
expulsive power of the uterus is undiminished, in fact, labour is stated to be
rapid under such conditions. Such facts appear to point to the thesis that the
uterus is under the control of both vago-tropic and sympathico-tropic fibres,
and that when inhibitory impulses from the lumbar cord are cut off the
sympathetic tonic stimuli have full play. If such is the case, may not a
remedy for the atonic uterus lie in the intrathecal injection of stovaine or
tropacocaine ?

REFERENCES.

[1] Polano, Mitnch A led. War he use hr., 1908, lv, p. 1178. [2] Kreiss, Zentralb. f. Gyn.,

1913, xxxvii, p. 1805. [31 Wyatt, Journ. Obst. and Gyn., 1911, xx, p. 60. [4] W”alls, Trans.

North Eng. Obst. and Gyn. Sac ., January 20, 1911. [5J Harris, Journ. Oust, and Gyn. Brit.

Emj)., 19i4, xxv, p. 186; Proceedings, 1913-14, vii (Sect. Obst. and Gyn.), p. 238. [6j Marsh,

Journ. Amer. Med. Assoc., 1912, lix, p. 940. [7J Huggins, A/nrr. Journ. Oust , 1922, lii, p. 412.

[8] CiOLTHORN, Journ. Amer. Med. Assoc., 1913, lxi, p. 1354; Surg. Gyn. and Obst., 1914, xix,
p. 492. (9) Hosaka, Japan Med. World, 1922, ii, p. 229.

DISCUSSION.

Mr. Eardley HOLLAND said there was no doubt that Dr. Cameron’s results were
outstanding, for his remarkable mortality of under 1 per cent, for such a long senes of
cases was only about half the average mortality as revealed by published statistics.
His own careful technique and the admirable conditions at the Glasgow Maternity
Hospital were contributory factors in his achievement, but there seemed no doubt that
the most important factor was his careful selection of cases. He took no risks as
regards the mother, and the number of craniotomies in cases uuder his care must be
very high; the question seemed to be—how many babies equal one mother? Mr.
Beckwith Whitehouse had discovered the virtues of spinal anaesthesia for Caesarean

Section of Obstetrics and Gynaecology

section, somewhat late in the day, as it must have been used many times during the
past few years by most obstetric surgeons. He (Mr. Holland) had personally used it
in about fifteen cases in most of which there was a special indication, such as eclampsia,
cardiac disease, concealed accidental haemorrhage or Graves’ disease; but in two cases
the method had been used for ordinary cases of contracted pelvis at the patients’ own
request. The effect on the uterus was indeed remarkable, for it remained in a state of
intense contraction and anaemia, as described by Mr. Whitehouse. This was a great
advantage for the closure of the uterine incision, for the thicker the walls of the uterus
at the time of the suture, the more muscle was gripped by the suture, and the stronger
would be the resulting scar. Further, if the sides of the incision were drawn into
apposition when the uterus was contracted, how much more would they remain in
apposition during relaxation, when the volume of the uterus became more bulky and
the sides of the incision tended to become relatively expanded ?

Mr. Miles Phillips said he had greatly appreciated Dr. Cameron’s paper, chiefly
for the large number of technical points it explained: some of these were new to him,
others he had already found to be of value. Dr. Cameron’s wonderfully low mortality,
he thought, was chiefly due to the wise rules he had formulated for the selection of
cases suitable for Caesarean section. The frequency of pulmonary complications in
these rickety patients had been greatly lessened, in his experience, by the use of
warmed ether. With regard to spinal anesthesia he would ask Mr. Whitehouse
whether there was likely to be any special difficulty in inserting the needle in patients
much deformed by rickets. When he had failed to remove the membranes satis¬
factorily from the lower segment of the uterus, he pushed a swab, soaked in antiseptic
lotion, from above into the vagina. He had also on several occasions been faced with
the difficult task of tracking and removing silk sutures (always thick twisted silk)
which had wandered from the uterine wall and were ulcerating into abdominal viscera.
Personally, he used catgut, and he always waited until the uterus had retracted and
its wall bad become as thick as possible before beginning to insert the sutures.

Dr. J. D. Barkis congratulated Dr. Cameron on his successful result. He had adopted
many of his methods and had found these of great value. He had never had occasion
nor had he felt it necessary to employ the instrument shown by Mr. Beckwith White-
house for dilating the cervical canal. Although he now performed Caesarean section
without waiting for the onset of labour he found that the cervical canal dilated well and
allowed for drainage. He thought Caesarean section under spinal anaesthesia a good
method under certain conditions such as severe morbis cordis, diabetes, and pulmonary
complications; the uterus retracted well, haemorrhage was not great, and the child was
born crying. But he took a modified view as to the use as a routine measure of
spinal anaesthesia for Caesarean section. It differed from spinal anaesthesia as employed
for other operations from this fact that morphia or scopolamine were excluded for the
sake of the child. In routine cases he preferred to perform the operation under a
general anesthetic and he found that gas and oxygen anaesthesia, with a little ether,
gave satisfactory results.

Dr. Herbert Spencer said he thought it was regrettable that selected series of
cases of Cesarean section should be published without stating the whole of the authors’
experience of the operation. Dr. Amand Routh’s paper' was of the greatest value as it
gave the whole of the experience of the author up to 1910. He hoped that Dr. Samuel
Cameron would publish the whole of his experience so that a basis for comparison with
the work of others would be available. Professor Bar, of Paris (who used silk ligatures
to sew up the uterus), had published a series of ninety-seven selected cases without a
death, a better series even than Dr. Cameron’s; but he (Dr. Spencer) thought that
both these obstetricians made such a selection as must lead to the unnecessary sacrifice
of many children’s lives. He (Dr. Spencer) saw no reason for refusing to perform
Caesarean section when the patient had been examined and the membranes ruptured
for twelve hours. He had often operated under these circumstances and even after
the application of forceps, and so far had only lost one case of Ciesarean section for

1 Proceeding8 t 1911, iv (Sect. Obst. and Gyn.), p. 161.

60 Whitehouse and Featherstone: Caesarean Section

contracted pelvis, a case already infected at the time of operation, which should have
been dealt with by total abdominal hysterectomy—an alternative to craniotomy not
mentioned by Dr. Cameron.

With regard to technique : he (Dr. Spencer) had published a case in which the uterus
had been inverted to separate the membranes; but he did not think this necessary or
advisable: it did not permit the inversion of the internal os where membranes were apt
to be adherent: in that case all that was necessary was to perforate the membrane by
forceps passed through the cervical canal, no dilatation being necessary. He did not
agree with Dr. Cameron’s remarks on silk sutures. He had only once had a sinus from
silk used to sew up the uterus, and, with regard to adhesions, his experience of repeated
Caesarean sections showed that adhesions did not occur, if the uterus was properly sewn
up with silk. He agreed with Dr. Cameron in condemning mattress sutures.

Dr. Cameron had not stated in his paper whether he sterilized any patient after
Caesarean section for contracted pelvis. It w’ould be interesting to know how many
craniotomies were necessitated by his method of selection and how many inductions of
premature labour had been performed. He (Dr. Spencer) had been supplied by the
Obstetric Registrar with the statistics for contracted pelvis at University College
Hospital for the last three years—total number of cases of labour, 5,647 ; induction of
premature labour, 118 ; all the mothers and 101 children surviving: Caesarean section,
33, all the mothers and 80 children surviving ; craniotomies, 4, all the mothers sur¬
viving ; the operation was done twice for hydrocephalus, twice for dead children; one
of the mothers had previously had twelve inductions of premature labour.

Section of ©batetdee anb <B\m*ecolo(j£.

President—Dr. T. W. Eden.

Angioma of the Vaginal Wall.

By Henry Briggs, F.R.C.S.

To this tumour clinical and pathological interest, if not surprise, is
attached. It was, without any note of local injury, found on July 28, 1922,
in a primigravida, aged 24, at the thirty-sixth week of gestation, partially
procident through the vaginal orifice and during the succeeding week under
observation its increase was slight but appreciable. There was no abnormal
varicosity of vulval or other veins. A sharp line of demarcation of the
apparently normal vaginal wall around the base of the reddish-brown tumour
is more consistently that of a new growth than of a progressive haematoma.
There was a reasonable reservation or doubt in diagnosis. Neither an angioma
nor a melanotic sarcoma could on available evidence be substantiated and a
haematoma also was to be doubtfully assumed. As a circumscribed polypoid
formation its size, If in. by § in. by | in., is unusually large for its superficial
site within the limited tissue range of the vaginal wall itself. Its free surface,
from epithelial erosion, was minutely porous and slightly bleeding. Its sessile
base was sharply defined on the normal vaginal wall and the lowest basal edge
was i in. above the fourchette. In treatment a ring or encircling excision on
August 7, 1922, was the most eligible means of securing a rapid primary union
with a very trivial sacrifice of normal structure.

The following is Dr. R. A. Hendry’s histological report: “The mass is
covered by a thinned out and, now incomplete, covering of stratified epithelium
—probably surface layer rubbed off during operation, &c. Underneath this,
for about half the depth of the “ tumour,” it is composed chiefly of blood,
some in more or less regular areas suggesting grossly distended vessels, the
remainder irregularly extravasated. Deep to this is a mass of loose oedematous (?)
tissue containing extravasated blood cells and dilated vessels.”

Verification by Professor Beattie was obtained.

The tumour and the microscopical section shown will, I believe, adequately
confirm the description given.

Section of Curettings.

Shown by Henry Briggs, F.R.C.S.

A MICROSCOPICAL section of curettings from a moderately abundant group,
obtained by an exploratory curettage on August 29, 1922, is under the
microscope : beyond excess of interstitial endometrial haemorrhage—an excess

Je—OB 1 [March 1, 1923.

62 Briggs: Curettings; Palmer: Secondary Leiomyosarcoma

for which the curette may or may not be alone responsible—there is the
welcome negative testimony excluding any new growth in a normally sized
uterus of a patient aged 48 with a healthy family of three at ages ranging
from 25 to 17 years. Before assuming that a menopausal functional
disturbance is the probable explanation the absence of chorionic villi from
the section of curettings is also recorded. The curettage was undertaken after
an exhausting three-weeks’ metrorrhagia following a ten-weeks’ suppression.
The curettage was followed by a slightly longer period of suppression, this
time for eleven weeks and three days. Then on November 17, 1922, an
apparently normal period, to begin with, repeated its blood-clots and excessive
loss once more. As this possibility had been anticipated and fourteen days
earlier a letter of inquiry had been posted, the patient came early for local
treatment by a gauze wick saturated with turpentine and lodged within the
body of the uterus on November 24, 28, 30, and December 4, a total of four
dressings coincident with the gradual arrest of the bleeding.

Three more precautionary dressings were applied on December 6, 13 and
January 10.

On February 13 a ten-weeks’ menstrual suppression ended in a normal
period—February 13 to 16, 1923.

In the choice of local remedies an intra-uterine dressing of turpentine in
my experience holds a foremost place in the treatment of haemorrhage usually
attributed to functional causes.

A Mass of Secondary Leiomyosarcoma following Subtotal

Hysterectomy.

Shown by A. C. Palmer, F.R.C.S.

M. L., SINGLE woman, aged 60. The menopause had occurred at the
age of 55, the periods having previously been normal. For three months
the patient had suffered from vague abdominal pains and a feeling of
tiredness ; for three weeks she had noticed a slight blood-stained vaginal
discharge. Ten days before admission to the hospital she consulted her
doctor who discovered an abdominal tumour. The patient was of moderate
height (5 ft. 6 in.) with a considerable amount of fat in the subcutis of the
abdominal wall.

A solid, slightly mobile, lobulated abdominal tumour was found rising out
of the pelvis, and reaching well above the umbilicus. The vagina was shrunken.
On examination under an anaesthetic, on May 5, 1921, the cervix was found to
be atrophic, but otherwise healthy. The original diagnosis of multiple fibroids
was thought to be correct, and a sub-total hysterectomy was performed,
a portion of the left ovary being preserved. Numerous adhesions were
encountered, and the removal of the large lobulated tumour was made
somewhat more difficult from the fact that one lobule rising from the upper part
of the supravaginal portion of the cervix had grown well out into the left
broad ligament.

Recovery was uneventful. The patient was provided with an abdominal
belt, and was discharged well.

Naked-eye Description of Specimen removed.

The uterus is greatly distorted by many large masses in its wall, the whole
measuring 27 cm. by 21 cm. by 13 cm. The peritoneum, for the most part

Section of Obstetrics and Gynaecology

smooth, has a few fine fibrous tags attached, and shows numerous areas of
dark red, subperitoneal haemorrhage. The cavity is 8 cm. long, up to 3 cm.
wide at fundus, and lined by smooth pink endometrium, up to 0*3 cm. thick.
The masses in the wall (up to 14 cm. in diameter) have a bulging, smooth,
pinkish-grey and white, whorled cut surface, with, in the case of the largest
at the fundus, numerous areas (up to 4 cm. by 2 cm.) flecked with dark red
haemorrhage. The smaller nodules are free from haemorrhage. A mass
(6*5 cm. by 6 cm.) projects from the left side of the uterus. It is devoid of
peritoneum; its cut surface is similar to that of the larger nodule and shows
many thin-walled vessels.

Histology. —A section taken from the projecting nodule showed the
histological appearance of a fibromyoma, while a section from the largest
nodule in the fundus showed the appearance of a leiomyosarcoma infiltrating
the muscularis of the uterus.

The question of further operation for removal of the cervical stump was
considered, and decided against. The patient was not seen again until
March 25, 1922, almost eleven months after operation. She came for advice,
largely on account of constipation which had been particularly troublesome for
ten days. For the first three days of the ten, there had been aching pain in the
left iliac region. This had passed, to be followed three days later by similar
pain in the epigastric region. During the preceding three months, the patient
had noticed her abdomen getting stouter and the abdominal belt had become
uncomfortable. On examination, a subcutaneous lump, the size of a tangerine
orange, was found in the lower end of the abdominal scar; the left hypo-
ohondrium and part of the epigastrium were occupied by a large, firm,
somewhat tender, fixed mass. A similar firm, fixed mass filled the lower
abdomen.

The patient was again admitted to hospital. She died suddenly from
pulmonary embolism, on the morning after admission.

The post-mortem examination was made by Dr. W. W. Woods, Assistant
Director of the Pathological Institute of the London Hospital. The following
are extracts from the report:—

Pulmonary Embolism and Recurrent Leiomyosarcoma ; Old Operation ,
Subtotal Hysterectomy. —“ A well defined rounded mass of sarcoma (17 cm.
diameter) attached to the vault of a greatly stretched vagina. Two discrete
masses (the larger 8 cm. by 6 cm. by 4 cm.) infiltrating the peritoneum of the
iliac colon. A discrete nodule (3 cm. in diameter) in the cave of Eetzius;
a discrete hard nodule (5 cm. diameter) in the subcutis of tbe abdominal wall,
in the lower end of the scar. A lobulated discrete mass (25 cm. by 18 cm. by
10 cm.) in the parietal peritoneum of the anterior abdominal wall at the
umbilicus, projecting into the left hypochondrium and epigastrium, and
attached to the omentum. No secondaries in soft inguinal, iliac or lumbar
glands. Red marrow in the lumbar spine. Slight distension of large intestines.
Great dilatation of urinary bladder, with injection of its mucosa, in the lower
part of posterior wall where stretched over and fused with the growth. The
lower end of the right ureter completely surrounded by growth; great distension
of right ureter (4 cm. circumference) above encircling growth, and hydro¬
nephrosis (size of an orange), with considerable fibrotic atrophy of right kidney.
Moderate hydronephrosis of left kidney. Five masses of externally laminated
clot (up to 8 cm. by 1*5 cm.) in bifurcation of, and in main trunks of,
pulmonary artery. Fluid blood in femoral and iliac veins. Slight oedema
of emphysematous lungs.”

64 Palmer: Leiomyosarcoma; Holland: Leiomyosarcoma

Description of Specimen after Removal The specimen weighs 11 lb. lli oz.

and consists of the secondary growth, pelvic organs, omentum and part of the
abdominal wall; it has been divided into two parts. One part consists of
the lobulated mass (25 cm. by 18 cm. by 10 cm.) attached to the abdominal
wall at the umbilicus, and adherent to the great omentum. Its cut surface
shows large areas of opaque, spongy haemorrhagic necrotic tissue; in other
areas it is white, cedematous, slightly whorled, and shows numerous small
cystic spaces. In the omentum are a few nodules (up to 4 cm.) with a spongy
cut surface. In the other part, the stretched vagina has been laid open;
adherent to its upper part is a mass (17 cm. diameter), the cut surface of which
is swollen, white, “ rubbery ’’ in some areas ; in others the tissue is opaque,
spongy and infiltrated with blood. The bladder is adherent to, and spread out
over, the mass. The left ureter passes through most of the mass. The cervix
is represented by a dimple in the vault of the vagina, and a probe entering the
dimple passes up the stretched cervical canal in the centre of the mass of
growth. The nodule (8 cm. diameter) infiltrating the peritoneum of the iliac
colon; the nodule (5 cm. diameter) in the subcutis of the abdominal wall
near the scar, and that (3 cm. diameter) in the muscles of the abdomen, are
hard; their cut surface is white and has a distinctly whorled appearance.
Sections from the two large masses, and the three smaller nodules mentioned,
show the histological appearance of leiomyosarcoma. Sections of six iliac,
inguinal and lumbar glands show congestion and oedema only.

A Leiomyosarcoma of a Fibromyoma removed by Subtotal

Hysterectomy.

Shown by Eardley Holland, F.R.C.S.

This case is similar to that just reported by Mr. Palmer in that the uterus
was removed by subtotal hysterectomy for a fibromyoma which subsequent
examination showed to be undergoing sarcomatous changes. In the case of
Mr. Palmer's patient the sarcoma recurred in eleven months ; in my own case
the operation was performed only four months ago and the patient, so far
shows no sign of recurrence. The patient is aged 42, and has two children,
the younger 10 years old; no miscarriages ; menstruation regular and not
excessive; no abnormal vaginal discharge. The chief symptom was difficulty
with micturition for the past two months, and a few weeks ago there was
retention of urine, for the relief of which a catheter was necessary. Examina¬
tion showed the uterus enlarged to the size of an eighteen weeks' pregnancy
and of a semicystic consistence. A diagnosis was made of fibromyoma,
probably undergoing cystic changes, and the uterus was removed on October
30, 1922, by subtotal hysterectomy. The patient made a smooth recovery
and when examined a fortnight ago presented no signs or symptoms of
recurrence.

The specimen consists of the body of the uterus and a single cystic tumour
with thick walls, both together forming an ovoid mass about 13 cm. by 11 cm.
by 11 cm. in size. The tumour has originated from the anterior surface and
left border of the uterus. Bisection of the tumour reveals an irregular cystic
space 6 cm. by 5 cm. lined by soft, smooth, yellow and pink tissue. The uterine
muscle can be traced entirely covering the tumour, although in places too thin
for measurement. The encapsulating muscle is everywhere easily separable

Section of Obstetrics and Gynaecology

from the tumour, the wall of which has, for the greater part, a whorled
appearance, and is composed of dense white tissue, save for numerous cystic
spaces which are scattered throughout, some of which are lined by pale yellow
tissue similar to that described above. In the uterine wall is a small seedling
fibroid. The endometrium is smooth and pink. Microscopic sections were
taken from four areas of the wall of the tumour, and all proved to be leio¬
myosarcoma.

About ten days after the operation, when I received the report on the
specimen from the Pathological Institute at the London Hospital, I con¬
sidered whether it would be wise to re-operate for removal of the cervical
stump; but I decided against this course, arguing that if the sarcoma cells
had permeated as far as the cervix they would also have permeated the
blood-vessels and tissues of the broad ligament and beyond.

DISCUSSION.

Dr. G. F. BLACKER, discussing Mr. Eardley Holland’s specimen, said he thought
that in any case in which subtotal hysterectomy was practised the tumour should be
opened before the operation was completed and that if the tumour showed signs of
breaking down, other than simple cystic degeneration, the cervix should be removed.

Mr. L C. RlVETT mentioned a case of cystic fibroid, containing one large cyst
weighing 14 lb., removed by operation at the Chelsea Hospital for Women.

Mr. L. Provis thought that if the growth in Mr. Palmer’s case had extended into
the broad ligament there would be no point in doing a total hysterectomy.

Dr. H. Russell Andrews said that his own experience of sarcoma of the uterus
was a gloomy one, the growth usually recurring within a short time of the operation.
In two cases at least secondary growths had been present when the patient was first
seen. He did not agree with Dr. Blacker that cystic change in a fibroid was usually
fine to sarcoma. In several cases in which he had removed large cystic tumours from
the utenis the microscope had shown no evidence of malignant disease and the patients
remained well.

Professor HENRY Briggs agreed with the experience of the previous speakers ;
sarcoma of the uterus recurred so speedily after the widest possible operations that he
thought Mr. Eardley Holland had adopted the most correct reasoning in his case. In
* non recurrent cases Professor Briggs believed that a cellular fibroma and not a
sarcoma was the truer description of the tumour: malignancy was not always frank in
its histology.

Two Specimens of Sarcoma of the Uterus.

Shown by J. D. Barkis, F.R.C.S.

Case I.

The specimen is composed of the uterus with its appendages together with
the vagina, bladder and rectum, which have been displayed by sagittal section
and the left half preserved.

The interior of the uterus in the recent state was occupied by a vascular,
spongy, friable growth, the greatest length of which measured 12*5 cm. and the
greatest width 10 cm. In its upper and anterior portions the growth can be
seen to have invaded the uterine muscle, which is thinned and nowhere
measured more than 0‘6 cm. in thickness ; the invasion has in some places
reached the peritoneum but has not penetrated it. In its lower portion the
growth is more vascular, is necrotic and hangs down as a tongue-like process,

66 Barris: Two Specimens of Sarcoma of the Uterus

the tip of which reaches to the level of the os internum. The cervix appears
healthy and the cervical canal is not dilated. The outer surface of the uterus
was in the recent state pink in colour, smooth in outline and covered by
numerous recent adhesions.

Secondary masses appear in three situations: —

(а) In the anterior vaginal wall, separate from the cervix and completely
surrounding the urethra, through which a probe has been passed, there is a
whitish, firm, rounded nodule, which measures 5 cm. in length and 3‘75 cm. in
width. The mass projects into the vagina but the vaginal mucosa appears
healthy. The bladder is much dilated and its walls are fasciculated owing to
the retention of urine due to the urethral growth.

(б) In the rectovaginal septum there is another mass similar in appearance,
which measures 2*5 cm. by 2*5 cm. Neither the mucous membrane of the
rectum nor that of the vagina is involved.

(c) In the position of the perineal body there is a third mass again of
similar appearance but considerably smaller, being about the size of a pea.

Microscopic Report .—Microscopic sections have been prepared from the
uterine growth, the vaginal walls and the secondary masses. The walls of the
vagina between the growths did not show any evidence of invasion by malignant
tissue.

I have shown the sections to Sir Bernard Spilsbury and he has kindly
furnished me with the following opinion: “ The sections show the presence of
a malignant growth having the characters of a sarcoma. The tumour consists
of masses of cells with fibrous and muscular septa separating the masses.
Most of the tumour cells are spherical or oval and show some differences in
size, being on the average rather larger than the cells of a small round-celled
sarcoma. Where the cells have a loose arrangement they are seen to have fine
cytoplasmic processes which connect neighbouring cells; there are also elongated
and fusiform cells and a few larger cells having the characters of small giant-
cells. Mitotic nuclear figures in fairly large numbers point to a rapidly growing
tumour. There are areas of degeneration and necrosis in the centres of the
larger masses of tumour cells, with haemorrhage into necrotic areas. The
tumour infiltrates widely the uterine wall and masses of the tumour cells
extend along small veins. The tumour is a polymorphic-celled sarcoma and
the character of the cells and their arrangement suggest a sarcoma of endo¬
thelial origin.”

The specimen was obtained from a multipara, aged 57, in whom the meno¬
pause had occurred six years previously. When first seen by me she had
complained of profuse vaginal haemorrhages for five weeks, together with
pelvic pain and frequency and difficulty in micturition. The condition was
judged to be inoperable. She died six weeks later with symptoms of acute
retention of urine and uraemia.

Dr. Kidman Bird, who asked me to see the patient with him, took so great
an interest in the case that he obtained permission to remove the pelvic
contents after death. I would like to record my sense of obligation to Dr.
Kidman Bird for affording me the opportunity of obtaining so interesting and
so valuable a specimen.

Case II.

The specimen consists of the left half of the uterus laid open by sagittal
section. The cavity of the uterus contained a growth very similar in size and
appearance to that described in the specimen just shown, but no secondary
deposit w r as found.

Section of Obstetrics and Gynaecology 67

The microscopic sections have been preserved and show the growth to be
a sarcoma.

Section (a) was taken from the point at which the tumour was attached to
the uterine wall, and shows the structure of a spindle-celled sarcoma invading
the muscle of the uterine wall. Many mitotic figures are seen, and they suggest
a considerable degree of malignancy.

Section (6) was taken from the part of the tumour projecting into the
uterine cavity, and shows on the surface an organizing blood-clot, deep to which
is granulation tissue, and beneath this sarcoma cells, which in places have
become necrotic.

The chief interest, however, lies in the clinical history. The specimen was
obtained by panhysterectomy from a multiparous married woman, aged 67, in
whom the menopause had occurred at the age of 50. She had not complained
of any symptoms except of profuse vaginal haemorrhage for three weeks only.

At the operation precautions were taken to prevent any portions of growth
from passing out of the cervical canal. It was not possible to sew up the
cervix, as the vagina was too narrow to permit of the necessary manipulations.
But the uterus was not handled directly, traction being made on the broad
ligaments only ; a cuff of vagina was made over the cervix as in Wertheim’s
operation; the vagina was divided between two clamps, and before removal of
the lower clamp the vagina was swabbed out. The patient made an uninter¬
rupted recovery.

In spite, however, of the precautions taken at the time of the operation,
bleeding recurred within two and a half months, and a red, spongy, friable growth
was found at the roof of the vagina. She died within three and a half months
of the operation from haemorrhage and cachexia.

The vagina was then almost full of growth, which could be felt extending
into the pelvis, but there were no secondary masses in the vaginal walls as were
present in the first specimen.

I bring forward these two cases to-night because they possess certain
striking features. The chief interest attaching to Case I lies in the position
and character of the secondary deposits. Case II illustrates the extreme
malignancy of these tumours.

It is remarkable that in both cases the duration of the initial symptom, i.e.,
vaginal bleeding, was short; being in the first five weeks and in the second
three weeks only, and yet in both cases the growth had by that time already
assumed a large size.

Chorion-epithelioma of the Uterus showing a very Extensive
Growth in the Uterine "Wall.

Shown by S. Gordon Luker, M.D.

The specimen was removed post mortem from a nulliparous woman,
aged 30, who died in the London Hospital, September 28, 1922, of haemor¬
rhage from chorion-epithelioma of the uterus.

The history is as follows: From January to June, 1921, she had irregular
bleeding, sometimes daily, and in June was sent into Walthamstow General
Hospital for curettage for miscarriage, but no further details can be obtained.
After this she was irregular till February, 1922, when she was unwell for one

Luker: Chorion-epithelioma of the Uterus

month, and was irregular again until July, 1922. She then had amenorrhoea
until September 27, when uterine haemorrhage occurred, which resulted in
her death. Abdominal pain was present during the last three or four
months; it was almost constant, but not very severe. There was a
history of cough at times, with streaks of blood in the sputum for a few
months.

She was sent to see me on September 18. She looked pale and ill, and
complained of abdominal pain. The right breast was just active. On abdominal
examination there was a median elastic swelling rising out of the pelvis to within
two finger-breadths of the umbilicus, rather tender on the left side. A loud
uterine souffle was heard, but there were no foetal heart, foetal movements, nor
ballottement. On vaginal examination the cervix was found to be greatly en¬
larged and expanded and slightly softened, as if some tumour was being
expelled from the uterine cavity, but the external os could not be felt nor
seen. The abdominal tumour was felt to be an enlarged uterus.

She was admitted to the London Hospital a few days later for further
investigation. She then showed symptoms and signs suggesting pneumonia,
which prevented any surgical measures.

On September 27 she had a very severe haemorrhage of several pints from
the vagina, and was treated by a hot douche and vaginal plugging and other
treatment for shock. Next morning she was a little better, and I made an
exploratory laparotomy. I found a very extensive haemorrhagic growth of the
uterus and pelvic organs bound down by adhesions. The condition was in¬
operable, and the abdomen was closed.

Post-mortem examination showed an extensive primary chorion-epithelioma
of the uterus, which had perforated the right lateral fornix of the vagina, from
which place fatal haemorrhage had occurred. The body of the uterus was per¬
forated in three places by the growth. The right ovary and broad ligament
were invaded by haemorrhagic growth. The uterine cavity was free from
growth, showing a smooth endometrial lining—a very unusual condition.
Secondary nodules were found in both lungs, the left suprarenal body and the
ileum.

A complete summary of the necropsy by Professor H. M. Turnbull, of
the Pathological Institute, the London Hospital, is appended. Sections from
the uterus and ovary and secondary growths are typical.

Summary of Necropsy, 1922.

P. N., aged 30. Died September 28; necropsy, September 29, 1922.
Traumatic anaBmia. Haemoperitoneum (l£ pints). Haemorrhage from chorion-
carcinoma of uterus. Recent operation : Exploratory laparotomy and removal
of portion of uterus for microscopic examination.

Lobulated, brown, red and purple, partly necrosed and cavitated, haemor¬
rhagic mass (15 cm. by 8 cm. by 8 cm.) of chorion-carcinoma, replacing the
myometrium of the right side of the body and cervix of the uterus, and greatly
elongating the uterus (14*5 cm. by 10 cm. by 6*5 cm.) Small haemorrhage
beneath, and in the substance of, the endometrium of the fundus; remainder
of endometrium smooth, cedematous and white. Smooth mucosa in cervical
canal (7*5 cm. long). Viscid mucus plugging cervical canal. Large perforation
by carcinoma through the right vaginal fornix. Direct infiltration by uterine
carcinoma of surface of adherent right ovary, forming haemorrhagic mass
(2*5 cm. diameter). Fibrotic corpus luteumin left ovary ; left ovary a mass of
thin-walled follicular cysts (from 2 cm. to 4 cm. diameter) with hypertrophied

Section of Obstetrics and Gynaecology

thecae intern®. Secondary haemorrhagic nodule (3*5 cm. diameter) in right
broad ligament. Direct extension of carcinoma from uterus into urinary
bladder, to form submucous nodules (up to 1 cm. diameter) in trigone. Very
numerous h®morrhagic secondaries (averaging 1 cm. diameter, occasionally
3 cm. diameter) throughout both lungs, most numerous in lower lobes. Ex¬
tension, surrounded by fibrous pleural adhesions, of one nodule through pleura
of diaphragmatic surface of left lung. Blood-clot in right main bronchus.
Diffluent hmmorrhagic secondary growth (4 cm. diameter) destroying greater
part of left suprarenal body. Hemorrhagic secondary (0*25 cm. diameter)
in submucosa of upper ileum. No secondaries in lymphatic glands.

Anaemia of kidneys and liver. (Edema and anthracosis of spleen. Mucous
catarrh of stomach. Milk spots on heart. Slight atheroma. Large fibrous
breasts, with considerable glandular tissue. Great anthracosis of bronchial
glands. Scar (3 cm. diameter) in right groin. Slight, wasted woman.

The points of interest in this case are as follows: (1) The chief symptom
was abdominal pain with amenorrhcea for the last three months; (2) the
uterus was very much enlarged, forming an abdominal tumour rising up to
within two finger-breadths of the umbilicus ; (3) death occurred from haemor¬
rhage from perforation of the right vaginal fornix by the growth ; (4) the size
and situation of the primary growth : (5) the extensive distribution of the
secondary growths.

The Treatment of Severe and Persistent Uterine Haemorrhage
by Radium, with a Report upon Forty-five Cases.

By Sidney Forsdike, M.D., F.R.C.S.

Severe and persistent uterine haemorrhage, at any age, is a source of
infinite anxiety to both the patient and doctor, and when the doctor has
exhausted the long and too often futile list of drugs, together with prolonged
periods of rest in bed, he is constrained to recommend curettage. Many of the
less severe cases are relieved by this measure, but in the type of case under
consideration the relief, if at all, is only measured by weeks and the patient is
too soon in the status quo ante ; and it becomes clear that something more
radical must be undertaken. «

At or near the menopause the above palliative measures may suffice to
pilot a patient through a stormy climacteric into the backwaters of post-
menstrual life, only too often, however, at the cost of transforming the patient
into a semi-invalid with the late prospect of complete neurasthenia. While
this method is possible for the well-to-do patient who can afford to remain in
bed, it is not feasible for the wage-earner or the mother of a family, and other
means must be adopted to deal with the condition promptly and finally.

The methods advocated for this condition are: (l) Hysterectomy;

(2) X-rays; (3) radium ; and the analysis of a report upon forty-five cases
treated by radium tends to show that it is the treatment of choice when
available.

Selection of Cases.

The type of case under consideration is sometimes described as the
bleeding uterus ”—a most descriptive term ; more commonly it is labelled
chronic metritis,” “ fibrosis uteri,” or “ chronic subinvolution.” But however
debateable the pathology, the one distinctive clinical feature is the excessive

70 Forsdike: Treatment of TJterine Haemorrhage by Radium

and uncontrollable haemorrhage with absence of any pelvic lesion to account
for it. This series of cases does not include the ordinary causes for haemor¬
rhage, but only cases which had been dealt with in the usual way and proved
refractory . to treatment. The criteria by which cases were selected were:
(a) The persistence of severe haemorrhage after operative treatment; (6) an
advanced anaemia, with shortness of breath, headaches, oedema of legs, &c.,
which had been treated palliatively for some time ; (c) cases in which the
patient had to spend some part of each month in bed.

Excluding the three cases in which an effort was made to modify the
period rather than to stop it, there were forty-two cases, the youngest patient
being 29 years and the oldest 55 years of age.

Three only were unmarried, and of the thirty-nine married four only were
nulliparae.

Number and Types of Operations.

Of the forty-five cases, twenty-six had undergone some form of operation
or combination of operations, including dilatation and curettage, removal of
polypi, amputation of cervix, oophorectomy or salpingo-oophorectomy, and
some of the cases had been curetted more than once. The remaining cases
had undergone medical treatment for variable periods, or their state was so
anaemic as to forbid any further effort at palliation.

Clinical Types.

Four cases were associated with fibroids, two of the interstitial variety,
and two small subperitoneal fibroids. The results were equally satisfactory,
and no change could subsequently be detected in the subperitoneal tumours.
While all the uteri were enlarged, they were broadly divisible into two groups
which might be best described as (a) systolic uterus ; (b) diastolic uterus.
The systolic uterus was hard, firm and regular, commonly straight, and
admitted a sound for 3 in. to 3i in.; it yielded little or no tissue to the curette
and gave the characteristic rasp of fibrosis uteri.

The diastolic uterus was bulky, retroverted, admitted a sound from 3$ in. to
5 in., and generally yielded a thickened and oedematous tissue. An interesting
point about this type of uterus was the fact that some months after irradiation
it was indistinguishable from the systolic type.

Technique.

In all cases dilatation of the cervix and an exploratory curettage were
performed. In cases in which the cervix and vagina were septic a preliminary
cleansing treatment was carried out. In all cases the radium was placed in
the uterine cavity, and only the gamma ray was utilized. The vagina was
packed with gauze moistened with liquid paraffin with the two-fold object of
supporting the radium and of keeping the bladder and rectum away from the
source of energy. A further precaution was adopted to maintain the bladder
in a flaccid condition by the introduction of a self-retaining catheter into the
viscus. In some cases it was necessary to stitch the vulva in order to support
the vaginal plug.

Dosage.

In three cases of patients between the ages of 20 and 26, 50 mg. of
radium were used for five hours. In the other cases 100 mg. were used for

Sectio?i of Obstetrics and Gynsecology

twenty-four hours, the object in the former cases being to influence the
menstrual period, in the latter cases to end it altogether.

I am inclined to think that 100 mg. is an unnecessarily large quantity for
the purpose, for in some later cases 75 mg. appear to have the desired effect.

A certain number of patients complained of pain while the radium was
in utero , but no more than when a stem is left in the cervix, and it disappeared
promptly with the removal of the radium. In a few cases post-anaesthetic
vomiting was prolonged and this appeared to be relieved by the withdrawal of
the radium. Some of the patients noted a frequency of micturition following
irradiation, a condition which was quickly relieved by barley-water, citrate of
potash, &c. Beyond the above, no untoward symptoms were noted. In all
cases nocturnal douches of salt and water are suggested for a period of
six weeks following the radiation.

Classification of Cases.

.4.—Aged 20 to 26, three cases.

B. —Aged 29 to 38, ten cases.

C. —Aged 39 to 50, twenty-two cases.

D . —Aged 51 to 55, ten cases.

Group A will be considered in detail; a selection of cases of other groups
is appended.

Case I, aged 20, married, no children. For one and a half years had been losing
fourteen to twenty-one days at a time and was only clear from seven to ten days.
September, 1921 : Dilatation and curettage, which did not relieve her at all, and she
attended out-patient department in October, November and December, and it was
evident that something more would have to be done. January, 1922 : 50 mg. radium
introduced into uterine cavity and left there for five hours. Late in January she had a
period of four days. February 28 : Another period lasting four days. March and
April: A more severe period. May : Admitted to another hospital where an ovary
was removed. Since then she has been quite well.

('a*e II, aged 28, Jewess and single. She had been losing daily for seven months
and was very anaemic. Had already been in hospital twice for the same condition.
(1) The first time for six weeks for observation and palliative treatment. (2) Second
time for dilatation and curettage; following this she was better for three months,
hut then relapsed into the daily loss. She was now thoroughly demoralized, and
despite her religion was anxious that hysterectomy should be done. In February, 1921,
I dilated the cervix and introduced 50 mg. of radium sulphate into the uterus, leaving
it there for five hours. She bled steadily for eleven days, during which time the
vagina had to be plugged. For the next six months she saw regularly each month
for from four to six days ; during that time she was in sole charge of a hemiplegic
father, and since then she has had no period at all. This, I think, must be attributed
to the close confinement and hard w r ork involved rather than to the influence of
radium.

Case III, aged 26, married; no children* Since marriage she had had severe
periods with pain for four years, which necessitated a couple of days in bed per
month. She w r as anaemic and had been treated with drugs for a considerable time.
January. 1921 : 50 mg. radium sulphate placed in utero for five hours. Has been
regular every month since, three-day type and without symptoms.

Group B .—Aged 29 to 38. There were ten cases, eight of whom had had
some form of operation, and two had been treated palliatively and had become
steadily worse. Aged 29, one; aged 34, two ; aged 35, one; aged 36, one;
aged 37, two; aged 38, three.

72 Forsdike: Treatment of Uterine Haemorrhage by Radium

Group C. —Aged 39 to 50, twenty-two cases, eleven of whom had [had
some form of operation, and eleven had been treated palliatively, but with
advancing anaemia and persistent haemorrhage. Aged 39, six ; aged 40, three;
aged 41, two; aged 43, one; aged 44, one ; aged 46, four ; aged 47, one ; aged
49, three ; aged 50, one.

Group D .—Aged 51 to 55, ten cases, five of whom had had some form of
operation and five had been treated palliatively. Aged 51, three; aged 52,
one ; aged 53, three; aged 55, three.

Symptoms following the Radium.

(1) No further loss in ten; (2) one period in seventeen ; (3) two periods
in eleven; (4) three periods in four.

The periods usually consisted of long drawn out “ shows ” varying from
three days to three to four weeks, the actual quantity of blood lost being
small. In cases where the exposure had been given immediately preceding a
period it usually resulted in a severe loss.

In five cases radium had to be employed a second time ; in three of them
I have little doubt that the first exposure would have sufficed, but the patients
were so thoroughly frightened by two prolonged shows following the first
exposure that it was considered advisable to comply with their demands. In
only two of these five was an anaesthetic necessary.

Vasomotor Symptoms.

Flushing as an index of vasomotor disturbance is liable to a very consider¬
able margin of error, and consequently is open to legitimate criticism. Many
women will omit mention of this symptom in a carefully taken history, and
yet, when it is suggested to them, they will admit experiencing the symptom
occasionally; where flushing is a real signal symptom it is mentioned
spontaneously. The graver vasomotor changes as signified by a profuse
perspiration or a generalized fall in blood-pressure, are never omitted in the
history, for they produce considerable distress. Consequently I have adopted
the plan of listening to their history patiently, and if they do not mention
vasomotor symptoms I have carefully refrained from asking them, and in the
after-result it was a fair conclusion that such symptoms did not exist.

Group A .—Aged 20 to 26. There were naturally no symptoms.

Group B .—Aged 29 to 38, ten cases. Eight had no symptoms; two
complained of flushes. This was the group in which one would have expected
to find vasomotor symptoms on the assumption that the ovary was being
affected.

Group C .—Aged 39 to 50, twenty-two cases : nine had no symptoms ; four,
flushing; three, flushing and sweating; six complained of flushing before
treatment, which remained the same afterwards.

Group D.—Aged 51 to 55, ten cases : six suffered from flushes before
treatment and remained much the same; four made no mention before or
after.

What is the Cause of Radium Menopause?

Is it due to action upon the uterus, or the ovary, or both ? The available
evidence points to action upon the uterus solely in the majority of cases, and
is based upon {a) clinical, (fc) experimental grounds.

Section of Obstetrics and Gynaecology

(а) Clinical Evidence .—In the younger women aged from 29 to 38 only
two out of the ten mentioned flushes, where this symptom should have been
pronounced, on the assumption that the ovary was influenced. Again, in the
group 39 to 50 the symptom was not unduly increased, and only in three
cases was sweating added to flushing. Histological evidence is difficult to
obtain, for removal of the uterus following treatment by radium for this
condition must be very rare. However, by the courtesy of Dr. Miles Phillips,
of Sheffield, I have examined sections from two uteri after exposure to radium,
and a section of the ovary from one of the cases. In the uterine sections there
was a diminution in the number and size of the glands of the endometrium,
and fewer capillaries than normal, but in the ovary there was no change
suggestive of irradiation.

(б) Experimental Evidence .—The normally placed ovary is 8 cm. away from
the uterine cavity, and beyond the effective range of radium, but a prolapsed
ovary would be very much nearer and to some extent would account for variable
results. The uterus of a cat being bicornute, the conditions under which radium
is used clinically can be reproduced by the implantation of the radium in one
horn whilst the contralateral ovary is fixed by a stitch at 8 cm. distance from it.
The experiment was performed in this way. A pregnant horn was opened and
the foetus removed; the radium was then implanted and the horn closed by suture.
The ovary of the same side was lightly attached to the wall of the uterus, and
the opposite ovary was fixed at a distance of 8 cm. by suture and rubber tube.
The radium was removed in twenty-four hours* time. This experiment was
repeated, the animals being killed at intervals of twelve, twenty-one, and sixty
days. In none of the experiments did the contralateral ovary show any macro¬
scopic or microscopic change. In all the experiments the ovary of the irradiated
side shows a profound change, consisting of complete destruction of both large
and small follicles. The corpora lutea are broken up, and in the later survivals
there are only a few scattered lutein cells recognizable. Vessels are for the most
part obliterated, and few remain normal. The uterus on the affected side shows
atrophy of the endometrium, a diminution in the number and size of the glands,
and a diminution in the number of capillaries. There is no characteristic
change in the stroma cells, although they appear to be fewer; but in the later
survivals, there are no glands, few capillaries, and a great increase in connective
tissue with few stroma cells. [Photo-micrographs were thrown on the screen,
see figs. 1-6.]

I then endeavoured to show that the remaining normal ovary was func¬
tioning by breeding from a cat which had been exposed in this way, but hitherto
that ambition has not been gratified, mainly, I think, because the condition of
the animal and its environment tend to depress the sexual instinct.

Contra-indications.

The only contra-indication is a previous pelvic inflammation, and this is a
very real danger, for the pelvis may become filled with an inflammatory tumour
rising into the abdomen, the nucleus of which is an abscess deeply seated in the
pelvis and nearly impossible to deal with. I have experienced a case of this
kind in treating a carcinoma of the cervix, where one had to risk this evil in
order to combat the growth.

74 Forsdike: Treatment of Uterine Haemorrhage by Radium

Section of Obstetrics and Gynaecology

Fig. 3.—The same section under a high power shows some diminution in'stroma cells
with an increase in connective tissue.

Fio. 4. —The same exposure, survival for twenty-one days. Endometrium shows
pronounced atrophy, almost complete absence of glands and blood-vessels, and a poorly
staining stroma.

76 Forsdike: Treatment of Uterine Haemorrhage by Radium

Fig. 5.—The same section under a high power.

Fig. 6. —Endometrium under the same exposure, survival sixty days. The atrophy
is still more marked, with great increase of connective tissue, and paucity of stroma cells.

Section of Obstetrics and Gynaecology

Relative Advantages of Eadium, X-ray and Operation,

(a) Radium is suitable for all, with the exception of cases complicated by
inflammatory disease. There is no mortality and no morbidity, and only the
minimum amount of time is necessary for the treatment—from three to seven
days. There is no prolonged convalescence, stay in hospital or nursing-home.

1 There were no failures in this series. The one drawback is the comparative
scarcity of radium.

I (b) X-Rays .—The use of X-rays for the treatment of severe uterine haemor-

I rhage has been fairly successful, but it is accompanied by the following very

i definite drawbacks: (1) The X-rays are utilized to destroy the ovaries, and

I their use raises the objection that normal organs are being destroyed in order

to influence an abnormal organ, and this is accompanied by a considerable
proportion of cases exhibiting severe vasomotor symptoms (38 per cent.: Eden
and Provis). (2) The treatment is prolonged, lasting three to four hours on two
succeeding days, repeated at intervals of twenty-one days on four to six occasions.
(3) There is a danger that the treatment may be used without a diagnostic
curettage. (4) Ulceration of the bowel, superficial burns, &c., have been noted.
(5) Finally, a certain number of failures have been noted.

(c) Hysterectomy , despite its low mortality, is a severe operation and fre¬
quently associated with post-operative results which are difficult to assess, e.g.,
the profound depression and loss of morale not infrequently seen. There is a
more or less prolonged period of invalidism following any abdominal operation,
and a certain percentage of morbidity as shown by subsequent pain, herniae,
adhesions and constipation. Nevertheless, the operation is satisfactory inas¬
much as the bleeding is cured beyond a question, and the only criticism is that
j the subtotal operation leaves a useless cervix, too often a diseased cervix, and

I less frequently a cervix which may become the seat of a malignant growth, of

which I have met one example this year. The drawbacks of this particular
treatment to the wage-earner are the length of stay necessary in hospital, the
length of the subsequent convalescence, and the problematical complete
restoration of health.

Conclusions.

(1) In my opinion radium treatment should be the method of choice in all
uncomplicated cases of severe and persistent haemorrhage due to chronic
metritis, inflammatory disease of the tubes and ovaries constituting the sole
contra-indication.

(2) The radium menopause is not usually accompanied by any symptoms
attributable to action upon the ovaries, and it produces the least disturbance
of the patient’s economic life.

Epitome of Cases.

Group A .—Three cases, aged 20, 23, 26.

Group B .—Ten cases, aged 29 to 38. Aged 29, one ; aged 34, two ; aged
35, one; aged 36, one ; aged 37, two ; aged 38, three.

Group C. —Twenty-two cases, aged 38 to 50. Aged 39, six ; aged 40, three;
aged 41, two; aged 43, one; aged 44, one ; aged 46, four ; aged 47, one; aged
49, three; aged 50, one.

Group D ,—Ten cases, aged 51 to 55. Aged 51, three; aged 52, one; aged
53, three; aged 55, three.

Multipart, thirty-five; nulliparae, six ; single, four.

78 Forsdike: Treatment of Uterine Haemorrhage by Radium

Periods subsequent to exposure: Nil , ten; one, seventeen ; two, eleven ;
three, four.

Vasomotor symptoms: twenty-one had no symptoms; nine complained of
flushes after treatment; twelve had flushes before and after treatment.

Selection of Cases.

Case XXXVII, aged 29, multipara 3. Haemorrhage for seven to eight days every
fourteen days, severe loss. Dilatation and curetting, but the haemorrhage was worse,
not being absent for even one day. Had returned to hospital for a hysterectomy, for
which she had been prepared. Radium was suggested and given. The uterus
admitted a sound for 8 in., and the curette gave the hard rasp of fibrosis uteri. Two
prolonged periods followed, the loss, however, being comparatively slight. Then a
second exposure of radium, followed by a few days* loss and nothing has been seen
since.

Case XXVI, aged 37, multipara 8.—Had been losing excessively for many months,
and showed pronounced anaemia. Admitted to hospital; dilatation and curettage
January. Got steadily worse after discharge from hospital, and was uninfluenced by
drugs, and then a prolonged loss of eight weeks. June : Radium sulphate 100 mg. for
twenty-four hours. After leaving hospital she had a prolonged daily loss for seven to
eight weeks; then clear for two months, then a further daily loss of a month, made
worse by ergot, &c. Second exposure without anaesthesia, 100 mg. radium sulphate.
No further loss.

Case XXV, aged 50, multipara 4.—Daily loss with floodings ; large part of her time
spent in bed. Secondary anaemia pronounced. Uterus hard, regular and firm, a scanty
amount of tissue being removed : 100 mg. radium sulphate for twenty-four hours. Two
prolonged ’ shows of eight and seventeen days followed, the loss being small. The
patient was nervous and insisted upon further treatment. Second exposure given ; no
further loss occurred.

Case XXXII, aged 34, multipara 1.—Severe flooding for one year nine months, and
showed pronounced anaemic symptoms. Admitted to hospital, where dilatation and
curettage were done. The relief was very temporary, and two months later she was
losing as freely as ever. A period of medicinal treatment was fruitless, and she was
getting steadily worse. Six months after the former operation, radium was placed in
utero. Three periods followed, the patient again getting gradually worse, and so
radium was given a second time, and since that time there has been no further loss.

Case XII, aged 51, multipara 6.—Severe floodings and constant loss for many
months, which drugs did not influence at all; and she spent most of her time in bed.
She was not a good subject for a severe operation, and therefore radium was given a
trial. After the first exposure there were two prolonged shows, but the loss was com¬
paratively slight. However, the patient was demoralized, and insisted upon further
treatment, and accordingly a second exposure was given. A recent letter from her doctor
informs me that she had had no further loss, and she feels well.

Case XIX, aged 49, multipara 2.—Catamenia fourteen to seventeen days, every
twenty-one to twenty-eight days. Anaemia. Interstitial fibroid. Had been treated
by palliatives for some time, and was no better. Radium followed by one show* which
lasted tw’enty-one days. Has seen nothing since.

Case XXXIX, aged 89, single.—Severe and prolonged periods treated by palliatives ;
no relief. Small interstitial fibroid present; 100 mg. radium sulphate for twenty-four
hours. Two shows subsequently of two and ten days. No further loss.

Case XLII, aged 46, multipara 1.—Catamenia eight to ten days every twenty-one
to twenty-five days, with severe loss. Per vaginam two small sub-peritoneal fibroids,
the size of marbles, could be felt, one anteriorly and the other posteriorly. Exposure to
radium. One show of three days subsequently, then no further loss. The fibroid in
the anterior wall, by reason of its position in relation to the bladder, would have to be
removed if it showed any increase in growth. So far, however, it has remained of the
same size.

Section of Obstetrics and Gynaecology

DISCUSSION.

Dr. LAPTHORN Smith said that Mr. Forsdike had shown great energy in carrying
out this comparatively new treatment. While he (Dr. Lapthorn Smith) admitted that
radium was a powerful irritant when applied to the inside of the uterus, he was not sure
that, like X-rays, it did not act rather by partially sterilizing the ovaries. None of the
women and none of the cats to whom it had been applied had subsequently had any
offspring. As far as the women over 45 were concerned, it did not make any difference
whether it sterilized the ovaries or not, as long as it cured the haemorrhage. Some of
the members of the Section might remember Professor Batty’s operation. He was one
of the founders of the American Gynoeological Society, and was one of the first to-
remove ovaries for the sole purpose of stopping h»morrhage. He (Dr. Lapthorn Smith)
could testify to its efficacy in many cases. But it was not justifiable treatment in the
ease of a woman younger than 45, because there were other equally effective measures.
He alluded to Apostoli’s method and to atmocausis, and the use of ergot and
calcium.

Dr. G. F. BLACKER said he had been treating haemorrhage from the uterus at the
menopause, from small fibroids, and in cases of so-called functional menorrhagia since
1916. He had altogether had seventy-seven of these cases, and his results had
been uniformly good. Kadium was a specific for climacteric haemorrhage. It should
only be employed in small uncomplicated fibroids: any tumours larger than the preg¬
nant uterus at the fifth month should be operated upon. He regarded any pelvic com¬
plication, such as disease of the appendages, as a complete bar to the use of radium.
He had used large doses both internally and externally. The method was without
danger in carefully selected cases. He had recently been collating his cases and the
results had been published in the Lancet , March 8, 1922. He thought Mr. Forsdike
was a little too optimistic, and that he would no doubt find that if he followed up the
after-course of his patients for a sufficient length of time, in some the hsemorrhage
recurred, and further treatment became necessary; this was particularly likely to
happen in cases complicated by the presence of fibromyomata. He (Dr. Blacker)
believed that the chief action of the radium was on the ovaries, and that this accounted
for the marked hsemorrhage which often followed immediately, for the symptoms of
the menopause, which were not uncommon, and for the effect following the application
of radium over the ovarian regions through the abdomen.

Mr. L. PROVIS said that he thought that X-rays were just as successful as radium,
if not more so in cases of menopausal hsemorrhage. There was no necessity, with
\-rays, for any ansesthetic. The action of radium was probably chiefly on the ovary,
but it had also a local action on the uterus.

Dr. H. RUSSELL Andrews said that he could not believe that the action of a tube
of radium in the uterus had produced vesico-vaginal and recto-vaginal fistulse. He
suggested as a possible explanation of the case mentioned by Mr. Provis that the vagina
had been inefficiently packed, and that the radium had been expelled into the vagina
^oon after its insertion into the uterus.

Mr. Sidney FORSDIKE (in reply) said that the amount of interest shown in his paper
was very gratifying. Dr. Lapthorn Smith had mentioned atmocausis and electricity
in the treatment of this class of case: he (Mr. Forsdike) was under the impression that
these methods had long since been abandoned—in any case he had had no experience of
them. Dr. Lapthorn Smith had also dealt with gauze plugging, calcium salts and ergot;
these were of course all temporary measures, and did not touch the problem of radical
treatment. Incidentally in the particular class of case under consideration he (Mr.
Forsdike) had always found that ergot aggravated the hsemorrhage. He entirely dis¬
agreed with Dr. Blacker on the question of treating fibroids by radium; he did not
think that radium had any part to play in the treatment of these tumours save as a
preliminary to operation, and in cases such as those quoted above, where the hsemorrhage
was the leading symptom, and the small fibroids merely an expression of the general

80 Forsdike: Treatment of TJterine Haemorrhage by Hadium

condition of the uterus. For a case of fibroids very much smaller than a five months'
uterus, where the fibroids demanded treatment at all, his opinion was that myomectomy
or hysterectomy was the proper treatment. He had already pointed out that pelvic
inflammation was an absolute contra-indication, but the fact that some other surgeon
had removed a tube and ovary from a patient for excessive haemorrhage did not deter
him from exposing them to radium so long as he could not satisfy himself that pelvic
inflammation existed. Again, he differed from Dr. Blacker in the question of the
scarring of the endometrium. In none of his experimental cases was there any
evidence of scar formation. In reply to Mr. Provis, with regard to the length of time
required for the treatment of this condition by X-rays, and the occasional fatality
following it, he (Mr. Forsdike) had only quoted information from a paper by Dr. Eden
-and Mr. Provis, read before the Section just two years ago. 1 With regard to the
formation of fistulse, he could not conceive of this happening where the radium was
placed in ntero under proper conditions.

1 Proceedings , 1921, xiv (Sect. Obst. and Gym), pp. 282-303.

Section of ©botetrico ant> (ItynaecoloQS.

President—Dr. T. W. Eden.

A Calcified Tumour of the Recto-vaginal Septum.

By L. Carnac Bivett, F.R.C.S.

A CALCIFIED mass 2 in. (5 cm.) by li in. (4 cm.) by li in. (3 cm.) removed
from the recto-vaginal septum of a woman, aged 54.

The patient complained of pain low down in the back, some straining and
tenesmus. On vaginal examination the mass was felt in the lower half of
the posterior vaginal wall. Per rectum , the mass was felt lower and more
superficially. Under anaesthesia the sphincter ani was stretched and, with one
finger in the vagina, the tumour was pressed downwards until it appeared
at the anus. The rectal mucous membrane was incised and the tumour easily
shelled out. The patient made an uninterrupted recovery.

The interest of this specimen lies in the question of its origin. Is it an
adenoma of the recto-vaginal septum which has become calcified ? Is it a
subperitoneal fibroid which has become detached and migrated through the
floor of the pouch of Douglas ? Or is it a calcareous deposit in the rectal wall ?
This last seems to me to be a possible explanation as the tumour appeared to
be immediately under the rectal mucosa.

Dr. Lapthorn SMITH said he had seen two other conditions which he would
suggest as possible explanations of the presence of such a hard stone as the one shown
and removed from the posterior vaginal wall. One was a phlebolith which had formed
in a vein and was about half the size of the specimen shown. The other was the
remains of an abscess which had never been recognized until many years later when
the liquid had been absorbed and the solid part, probably phosphates, had been calcified
by accretion of lime salts, a method of Nature for walling off foreign matter. It was
quite likely to be one of the other conditions mentioned, but those he (Dr. Lapthorn
•Smith) had stated might be added. It was certainly very rare.

A Ruptured Hsematoma of the Ovary, with Extensive
Intraperitoneal Haemorrhage.

By L. Carnac Rivett, F.R.C.S.

This other specimen is a lutein cyst which occurred in a single woman,
aged 25, who was seized with sudden abdominal pain and collapse. On
examination the abdomen was tender over the right lower quadrant, and
appendicitis was diagnosed. Laparotomy was performed and about 25 oz. of
blood and clots were found in the peritoneal cavity. The cyst was shelled ont,

J y -OB 1 [May 3, 1923.

82 Rivett: Ruptured Haematoma; Donald: Adenomyomata

and a couple of haemostatic stitches put in the ovary. The patient made an
uninterrupted recovery.

Cases of rupture of a hramatoma of the ovary giving rise to such extensive
haemorrhage are sufficiently rare to be worth recording. There was nothing
to indicate ectopic gestation, and a section is exhibited.

The Clinical Aspects of Adenomyomata of the Female

Pelvic Organs.

By Archibald Donald, MJD., Ch.M.

(Professor of Clinical Obstetrics and Gynscology , University of Manchester.)

Terminology. —An adenomyoma is, as the name implies, a tumour composed
of glandular and muscular elements. The glands are lined by columnar cells
and are surrounded by, or rest on, unstriped muscle cells and a stroma of
small cells. The microscopical picture closely resembles that of the endo¬
metrium. For this reason the name of “ endometrioma ” has been suggested,
but, as that name implies the acceptance of a theory as to the mode of origin
of these growths, it seems to me better not to use it. At the same time, there
is no doubt that the elements in adenomyomata, in some cases at least, behave
like those in the endometrium. In some cases the “ cytogenous tissue ” takes
on a decidual reaction during pregnancy—and in many cases the spaces are
filled with altered blood, the result of haemorrhage during the menstrual
periods. It seems probable that this causes the acute dysmenorrhoea which
is so common a symptom in adenomyomata. Some writers believe that the
mass of glandular and muscular tissue found between uterus and rectum—
adenoma of the rectovaginal space—is the result of inflammation and not
a true neoplasm, and have invented such strange terms as “ adenomyositis.”
But even if this view is correct for swellings in that particular place, it does
not apply universally. It seems best for the present to keep to the original
term of adenomyoma. Further research may enable us to find a more suitable
name and one which will embrace the different varieties of the disease.

Situations. —Adenomyomatous growths are not confined to the female
pelvic organs. They are found in the intestinal canal and in the umbilicus.
In the pelvis they are found in the uterus, in the round ligament, Fallopian
tube, ligament of the ovary, ovary, and rectovaginal space. They may be in
only one of these situations, or in more than one, and may even be found
in all six simultaneously. It is not possible to state definitely the relative
frequency in which they are found in each of the situations noted. At one time
it was thought that they were the most common in the uterus and occurred
rarely in the ovary. Now it seems fairly probable that the ovary is a frequent,
if not the most common, site of these growths; that the pouch of Douglas is
also somewhat frequently involved; and that the other structures—including
even the uterus (if that is not included in the rectovaginal space)—are less
frequently affected.

Infiltrating Ovarian Cysts with Tarry Contents. —In a previous communi¬
cation (< Journal of Obstetrics and Gynaecology of the British Empire , Autumn,
1922) I have remarked on the frequent association of these cysts and
adenomyomatous growths in the rectovaginal space. It is a type of cyst
long known to all gynaecologists, but its true nature has only recently been

Section of Obstetrics and Gynaecology

discovered. These cysts are situated on the back of the broad ligament,
are often bilateral, never attain to a very great size—varying generally from
that of a walnut to that of a Jaffa orange. They are nearly always deeply
embedded in the broad ligament and adherent to the surrounding structures in
the pelvis. They are peculiar in that they possess powers of infiltration
or dissection and yet are not truly malignant. They contain somewhat thick,
viscid contents of a tarry or chocolate-brown colour. If these tumours are cut
in serial sections and carefully examined, adenomyomatous elements are
generally found; sometimes the muscular element is missing, but in' others
the glandular, cytogenous and muscular constituents can plainly be seen.
In a large number of cases they are associated with adenomyomata in the
rectovaginal space. They are now recognized as adenomyoma of the ovary,
and it seems possible that, in some cases at least, the adenomyomata of the
pouch of Douglas are derived from them, just as the warty growths in the
peritoneum are caused by the rupture of a papilliferous ovarian cyst.

Cases .—As comparatively few cases of operation for adenomyoma have
been so far published in this country, a report of my recent experience may
be of interest. The total number of the cases is sixteen. The operations were
all performed last year, that is, between January and December, 1922. The
number is not sufficiently large to allow of any dogmatic conclusions being
drawn with reference to onset, symptoms, &c., but the record of the cases will
facilitate comparison with other lists.

Age .—The youngest patient was 23 and the oldest 47. Half of the cases
were under 40 and the other half between 40 and 47. None of the patients
had reached the menopause.

Social Conditions and Obstetric History .—Two of the patients were single.
Of the fourteen married patients, five, or nearly one-third, had never been
pregnant. Of the remaining nine, five patients had one or more miscarriages.
These figures (for what they are worth) seem to indicate a relationship between
adenomyoma and sterility, and abortion.

Symptom .—The symptoms of which complaint was made were dysmenor-
rboea, pain or pressure in the rectum, and dyspareunia. These symptoms
occurred in various combinations. Dysmenorrhoea was much the commonest
symptom ; it occurred in thirteen of the cases, if we include one case in which
the pain in the rectum was greatly aggravated at the time of the period.
Sometimes it occurred before the period began and was generally most acute
during the first day or two of the period. In the remaining three cases there
is no note of it, but in one of these, pain in both iliac regions and pressure on
the rectum was more or less constant. Pain in the rectum was noted in three
cases and dyspareunia in four cases. As regards this last symptom, it is probable
that no direct questions were asked; otherwise I think the numbers would
have been larger. There was complaint of profuse haemorrhage at the periods
in seven cases, or nearly half, but there is reason to believe that this is not a
symptom of adenomyoma, unless the growth is actually in the uterus, but is
generally due to some other co-existing condition of the uterus.

Physical Signs .—These consisted mainly of the following conditions:

(1) Hard or irregular swelling or nodules felt through the posterior fornix.
This condition was present in twelve, or three-quarters of the sixteen cases.

(2) In nine cases there was indefinite resistance at one or both sides of the
uterus; and in three of these, definite enlargement of the ovary was made out.

(3) In four cases the uterus was retroposed and its mobility was much limited.

Table of Cases of Adenomyoma of the Female Pelvic Organs in which Operation was Performed.

84 Donald: Adenomyomata of the Female Pelvic Organs

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66 Donald: Adenomyomata of the Female Pelvic Organs

Section of Obstetrics and Gynaecology

Diagnosis .—The disease was diagnosed in almost every case, if not with
certainty, at least as a probability, owing to the conditions which have here
been noted. Sometimes only one of the signs was discovered; sometimes
two in combination. In several cases the history suggested the possibility of
adenomyoma: very acute dysmenorrhoea beginning before the onset of the
period or during the first day, and especially so if the pain has come on some
years after the periods have been established, is always suspicious. Pressure
on the rectum is another important symptom, as is also acute dyspareunia.
Indefinite resistance at the sides of the uterus is suggestive of adherent, tarry,
ovarian cysts. The hard mass at the back of the uterus suggests the recto¬
vaginal adenomyoma. The easiest case for diagnosis is that in which a distinct,
hard tender nodule is felt through the posterior fornix. This nodule is
generally not much bigger than a pea, and may be smaller—sometimes there
is a collection of nodules. The retroposition and limited mobility of the
uterus suggest adhesion of the uterus to the rectum.

Conditions found at Operation .—Tarry cysts of one or both ovaries were
found in eleven cases (in three cases unilateral, in eight cases bilateral). In
one other case, a cystic ovary containing clear fluid was removed, but the
pathologist succeeded in finding adenomyomatous tissue. The growths in the
pouch of Douglas varied considerably, from a hard mass that stretched from
side to side and filled the pouch of Douglas, to a small nodule on the anterior
wall of the rectum or posterior wall of the uterus. Where a mass existed, the
rectum and posterior aspect of cervix and uterus were involved. In the other
cases where only nodules could be found, the rectum was adherent to the
lower part of the uterus as high as the internal os and had to be dissected off.

Operations .—The operations in the sixteen cases were as follows : (1)
Panhysterectomy or subtotal hysterectomy with dissection of adenomyomatous
growth from the pouch of Douglas or rectal wall, twelve cases. (2) Removal
of one ovary and dissection of nodules from uterus and rectum, one case.
(3) Removal of fibroid by myomectomy, separation of rectum and dissection
of small adenomyoma from the rectal wall, one case. (4) Removal of tarry
ovarian cyst, one case. (5) Dissection of rectovaginal growth only, one case.

As will be seen from this table the operations varied very considerably in
severity. In twelve of them, however, panhysterectomy or subtotal hyster¬
ectomy had to be performed in order to make it possible to dissect out the
adenomyomatous growths in the pouch of Douglas. All these cases were
difficult, but the difficulty varied according to the size of the growths in the
rectovaginal space. There was one death, which followed a very difficult
operation in a patient whose pelvis was widely infiltrated with the growth. In
three other cases, the rectum was opened and had to be covered by suture.
In one of these a rectovaginal fistula persisted for six weeks. In one case all
that was required was to separate the adherent rectum from the uterus and
dissect out an adenomyoma from the rectal wall. Dissection in this region
has to be very carefully performed, as any serious weakening of the rectal wall
may lead to subsequent disaster. The remaining three cases were unusual—
in one there was the removal of a tarry cyst of one ovary, with no other
complication : in another, the removal of a fibroid tumour by myomectomy in
addition to the removal of a small adenomyoma of the rectovaginal space ; and
in the remaining case the removal of a clear cyst of one ovary (which the
microscope proved to contain adenomyoma) with dissection of some nodules
from the rectum.

88 Donald: Adenomyomata of the Female Pelvic Organs

Pathobgical Reports .—I have pathological reports on every case; the
investigations have been made by Dr. Addis, to whom I am much indebted, in the
clinical laboratory of St. Mary's Hospital, Manchester. Microscopic evidence
of adenomyoma was found in every case except two (Cases XI and XVI, pp. 85,
86). In Case XI a tarry cyst of the left ovary was removed, but there was no sign
of growth elsewhere. The cyst was very adherent, and had to be dug out of the
back of the broad ligament, and corresponded in every respect to the tarry
cysts in the other cases ; but the microscope failed to show the usual glandular
structures. Case XVI was more striking. It was a typical case of widespread
adenomyomata in the ovaries and pouch of Douglas, but so far the microscope
has not confirmed the diagnosis made by the naked eye. The specimen is still
being investigated. In the remaining fourteen cases the presence of adeno¬
myoma was confirmed by the microscope; in all of these it was found in the
growths removed from the rectovaginal space or from the posterior wall of
the uterus or anterior wall of the rectum. In the eleven cases of tarry ovarian
cyst, microscopic confirmation of adenomyoma was obtained only in two cases ;
but in one other case, in which an ovarian cyst with clear contents was
removed, typical adenomyomata were found by the microscope in the cyst
wall. There is no doubt that the microscopic investigation of these tarry cysts
is very difficult. The effusion of blood, which is the characteristic property of
these growths, destroys the glandular element, and it may require a very long
and patient investigation of a cyst before definite microscopic evidence is
obtained. The larger and older the cyst, the more complete is the destruction.
But the naked-eye appearances and general characteristics are quite sufficient
for diagnosis.

General Remarks .—It is generally assumed that adenomyomata belong to
the very rare kinds of tumour, hut the experience I have here recorded seems
to showthat they are much more common than is generally believed. Looking
back on my operative work of many years, I am fully convinced that I have
had many such cases in the past that I did not recognize even at the operation.
They were generally taken to be cases of pelvic inflammation, or ovarian cysts
that had become infected. The ordinary blood cyst of the ovary is not
adherent, and it is filled with fluid or clotted blood, which is of the normal
colour, and has not the viscid consistence of the contents of a tarry cyst.
Sometimes the contents of one loculus of a large multilocular ovarian cyst
may have a dark colour, due to the effusion of blood, but these cysts have not
the penetrating power of the adenomyomatous cyst. The adhesion of the rectum
to the lower half of the uterus is a condition that one has often met with, but
we have failed to appreciate its significance. There is little difficulty in recog¬
nizing the condition when the abdomen is opened. The existence of
adherent cystic ovaries with viscid tarry-coloured contents is present in
about 75 per cent, of the cases. The adhesion of the rectum to the
lower part of the uterus and the obliteration of the pouch of Douglas is
practically always present in rectovaginal adenomyoma, and when the
adhesions are separated, if there is not a distinct mass, the hard, round, little
bodies will be felt.

The recognition of the conditions before operation is not very difficult if
they are borne in mind at the time. The indefinite resistance on each side of
the uterus, indicating tarry ovarian cysts; the retroposition and limited
mobility of the uterus, due to adhesion of the rectum ; or the hard irregular
mass or firm, round nodules like gunshot are all suggestive, if not con¬
clusive, of the diagnosis. The severe dysmenorrhoea coming on before

Section of Obstetrics and Gynaecology

the period and lasting for the first day or longer, especially if this has
been increasing during adult life, should lead us to suspect the condition.

Possibly a critic may ask, “ Why operate on these cases ? Why not leave
them, and see if they develop ? ” In the first place, most of them would be
operated upon even if they were not recognized as cases of adenomyomata.
The typical uterine adenomyoma is generally mistaken for a fibroid, and opera¬
tion advised. When the growth exists in one or both ovaries, causing enlarge¬
ment which can be felt, ovariotomy is recommended. In the diffuse forms of
growth which simulate pelvic inflammation, an exploratory operation is
generally carried out. One or other of these two latter conditions existed in
the majority of my cases. There remains the case in which there are one or
more small masses to be found in the pouch of Douglas. The symptoms in
these cases are always much out of proportion to the size of the growth. The
dysmenorrhcea, dyspareunia, and rectal symptoms are sufficient to induce the
patient to seek relief. In two of the cases in the table (Cases II and XIV,
pp. 84, 86), curretting had been performed in the hope of obtaining some relief;
but both patients had returned with the request that something more should
be done.

The further question arises as to the nature of the operation which should
l)e undertaken in the various types of case. The conclusions at which I have
arrived are the following :—

(1) When both ovaries contain tarry cysts and there is a mass or some
nodules in the rectovaginal space, a radical operation is indicated. When
both ovaries are removed there is no object in leaving the uterus, and a
panhysfcerectomy gives the easiest access to the nodular growths between
cervix and rectum.

(2) When one ovary only is diseased but there is a large mass involving
rectum and uterus, the radical operation is still advisable.

(3) If one ovary only is affected and there are merely some small nodules
in the pouch of Douglas, a conservative operation may be sufficient—removal
of the affected ovary and dissection of the nodules after separation of the
rectum. But if this course is followed, it is necessary to examine the
second ovary very carefully, as the tarry cysts are sometimes small; and it is
also advisable that the patient should report from time to time.

(4) The conservative method applies still more to those cases in which
the only lesion found is the presence of one or two small nodules in the recto¬
vaginal space.

Since the preceding part of this paper was written, I have been able to
procure the article in full on 14 Perforating Haemorrhagic (chocolate) Cysts of
the Ovary/’ which was communicated by Dr. John A. Sampson to the American
Gynecological Society in 1921. I have already in my previous paper quoted
an abstract of this communication, which appeared in the British Medical
Journal of February, 1922, but that contained no reference to the methods of
operation nor to the clinical symptoms or treatment. It is of interest to
compare Dr. Sampson’s conclusions with my own. The age-incidence in his
cases was from 26 to 47—only two cases were under 30, and none occurred
after the menopause. As regards pregnancy, of the fifteen married patients in
his list, nine had never been pregnant. He concludes from this, 44 It would
seem that this condition is likely to occur in women who are sterile.” There
is no mention, however, of miscarriages in the remaining six patients.
Dysmenorrhcea was noted in only eleven of his twenty-three cases. This

90 Donald: Adenomyomata of the Female Pelvic Organs

finding is in marked contrast to my own observations. Menorrhagia he
found in six cases, but in three of these myomata were found. Pain was
present in only fifteen of the twenty-three, and its location and severity varied.
It will thus be seen that there was not the definite indication of trouble that I
found in my cases. This may be due to the fact that the ovarian cysts in
Dr. Sampson's cases were usually small. The majority were under 4 cm.
in diameter, and the largest measured 9 cm.

I regard Dr. Sampson's paper as the most important contribution that we
have had to this difficult subject. He is still carrying on investigations, and
has reserved judgment on some of the problems involved; but he is fully con¬
vinced that when we find adenoma in the ovary and also in the recto-vaginal
space the growth in the ovary is primary.

DISCUSSION.

Dr. Herbert Spencer said he was much interested in Professor Donald's cases of
blood-cysts of the ovary and their relationship to 44 adenomyoma ” of the utero-rectal
space and was glad to find that Dr. Donald did not employ the erroneous term 44 recto¬
vaginal septum,” in which these growths did not usually occur. He also agreed with the
author in objecting to the term 44 endometrioma ” as applied to the growth in the ovary.
The presence of glands in the ovary was not rare; but it would require better sections
than those exhibited to persuade him that the stroma was identical with the cytogenous
tissue of the uterine endometrium. The presence of a stroma resembling that of the
uterine endometrium was observed in some cases and this condition had been known
for many years—having been described by Pick, in 1905, as adenoma endometrioides.
In many of the cases, however, the blood cysts showed no such stroma and some of
them were undoubtedly corpus luteum hsematomata of which an example had been
shown that evening and he had removed one thirty-two years ago. He had removed
an adenomyoma of the recto-uterine space from a virgin suffering from severe dys-
menorrhcea, by total hysterectomy, opening the anterior fornix and amputating the
body, to clear the field, before removing the cervix and the growth attached to the
rectum. He did not think subtotal hysterectomy was a suitable operation for these
cases. In this instance there were no macroscopic cysts in the ovaries, which were not
removed, and the patient had remained well nine years later. In another case the
uterus and ovaries were removed by vaginal hysterectomy for cystic ovaries and
adenomyoma of the whole of the posterior surface of the uterus. In this case it seemed
that the ruptured cysts had given rise to the adenomyoma. In order to exclude the
uterine endometrium as a source he had made a coronal section through the middle of
the posterior wall: this did not contain any glands and showed that the growth came
from the peritoneal surface.

While blood-cysts of the ovary usually needed removal he thought the importance
of adenomyoma of the recto-uterine space was being exaggerated. The condition
w as much commoner than it was formerly thought to be : no doubt the 44 posterior
parametritis ” of old writers was often of this nature. One diagnostic point (the
presence of nipple-like projections in the posterior fornix) had not been alluded to by
the author. He (Dr. Spencer) had watched one of these cases for years without any change
occurring in the local condition, which gave rise to no serious symptoms. In view of the
difficult and dangerous operation for the removal of adenomyoma of the recto-uterine
space he thought few of these cases—except those attended by severe dysmenorrhoea or
other serious local condition—should be subjected to extirpation, which, when attempted,
was often incomplete and involved considerable risk of injury to the rectum

Dr. Russell Andrews remarked on the extreme interest of Dr. Donald’s com¬
munication and gave a short account of a case in which radium had been used with a
good effect in the treatment of adenomyoma affecting the uterosacral ligaments and
the bases of the broad ligaments. Three years earlier a very adherent left-sided ovarian

Section of Obstetrics and Gynaecology

blood-cyst had been removed in South America and an attempt had been made to
remove a hard nodular growth in the rectovaginal space. Three nodules were removed
but some indurated tissue was left. When he (Dr. Andrews) saw the patient he
considered that it was useless to attempt to remove the nodular growth, and Dr.
Fairbaim agreed with him. The patient was suffering very severe pain. After treatment
by radium the nodules became slightly diminished in size, the pain disappeared and the
general condition improved greatly. Six months later there was no pain or discomfort
but there was still a great deal of induration surrounding the rectum.

Dr. Herbert Williamson said that the Society was indebted to Dr. Donald for
focussing attention upon the clinical aspect of these important cases. The speaker
desired to direct attention to two statements of opinion commonly held which he
believed to be erroneous: (1) With regard to the question of leaving a small portion
of the growth adherent to the uterine wall; (2) with regard to the value of irradiation
in treatment. For example, in Dr. Lockyer’s classical monograph the following
passage occurred (p. 871). afc—-la

“ The portion adherent to the bowel wall should where possible be removed by blunt dissection.
Where this is not feasible owing to deep infiltration of the bowel-wall it seems unnecessary to
sacrifice the bowel by excision since small areas of ( growth ’ have been known to disappear. It
seems that infiltrated bowel-wall may safely be left if the bulk of the adenomyomatous material be
removed.”

And again on p. 444:—

“ All forms of radio-therapy.for adenomyoma are disappointing; only in one case

.have 1 heard of radium doing good. It is my belief that such treatment is liable to

excite the inflammatory process which is the pathological basis of the disease.' 1

He would quote two cases bearing upon these points :—

(1) That of a lady, aged 37, first seen by him in October, 1920. She had been
seen by Dr. Herbert Spencer, in 1914, who told her she had “ a small growth low
down on the side of the womb.” Shortly after this she returned to India and in 1917
consulted Major Bott on account of pelvic pain. He found a nodule the size of a large
walnut to the posterior and right side of the cervix extending into the base of the right
broad ligament and adherent to the anterior aspect of the rectum. Two years later, in
1919, she consulted him again because the pain had become more severe. Finding the
tumour had grown considerably he performed a complete hysterectomy. Major Bott
wrote:—

44 The fibroid was bo closely adherent to the anterior wall of the rectum that I had to leave a
small portion of it behind. As she has experienced some return of her old pain, and as she is
leaving for England, I have told her to come and see you.”

He (Dr. Williamson) saw her in October, 1920. She complained of severe rectal
tenesmus and of increasing difficulty in evacuating the bowel. On examination he
found a hard, tender mass, the size of a pigeon’s egg, in the situation of the recto¬
vaginal space, fixed to both vaginal and rectal walls. The growth had involved both
utero- sacral folds. Excision of a small portion showed the presence of dilated glandular
spaces in a cytogenous stroma. Dr. Cuthbert Lockyer saw the patient at this time
and advised colotomy and then an attempt at complete excision. He (Dr. Williamson)
decided, however, in the first place, to try the effect of radium, and he obtained from
the Radium Institute emanation equivalent to 100 mg. of radium metal contained in a
silver tube of 1 mm. thickness. On December 3, 1920, the tube was buried in the
growth and left in situ for thirty-six hours. On January 18, 1921, the growth was
found to have shrunk to about half its original size and a second tube of emanation
equivalent to 95 mg. of radium metal was inserted for twenty-four hours. Six weeks
later on examination he could feel no growth at all, but only a little thickening in the
situation it had occupied. She had lost the pain and there was no difficulty in the
action of the bowels. Since then she had been quite well.

1 “Fibroid and Allied Tumours (Myoma and Adenomyoma),” 1918.

92 Pugh : Graves' Disease and Thyroid Instability in the Cow

The second case was that of an unmarried woman, aged 82. Her periods were
normal until March, 1922. On the last day of this period she felt severe aching,
dragging pain in the right leg which lasted a week and gradually became easier. The
pain recurred with each successive period from March to September and became more
severe, always setting in on the last day of the period and persisting for seven or eight
days. She was obliged to give up work for that time and had difficulty in walking.
When examined on September 18, an irregular swelling was felt in the posterior fornix,
situated partly in the vaginal wall and partly in the cervix itself. It was a hard
nodular swelling about the circumference of a half-crown and it bled freely on touch.
The vaginal mucous membrane was adherent to it. Bimanual examination showed
that the growth was firmly attached to the uterus and hard fixed indurations were felt
in both broad ligaments and the uterosacral folds. The nodule projected into the
bowel and the rectal mucosa was fixed to it but not ulcerated. Sections of a portion
removed showed a stroma consisting mainly of fibrous tissue containing glands like
those of uterine mucosa and cystic spaces lined with epithelium. It was decided to try
the effect of hard X-rays and accordingly on September 10 a dose of 8H was applied
over the hypogastrium, and on September 11, a similar dose over the sacral region.
After this the periods ceased and the pain was lost. On January 5, 6, 8, and 9, 1928,
doses of 11H were applied over seven areas of the lower abdomen and back. When
examined on April 27, no trace of growth could be felt, but a puckered scar on the
vaginal wall marked the spot where it was previously situated. The uterus was freely
mobile. Per rectum no nodule was felt but a thickening over which the rectal mucosa
moved freely. There was very little induration in the pelvic cellular tissue, no more
than could be accounted for by the presence of scar tissue. Apart from troublesome
flushings due to the premature menopause the patient was quite well in all respects.

These two cases suggested that possibly in many cases radical operations were not
necessary and that treatment by irradiation ought to be given a more extensive trial.

Mr. W. W. King said that adenomyomata were relatively common in Sheffield.
He had had eighty-four cases under his care during the past ten years. Glandular
tissue of endometrial type was found in the ovaries in nineteen of the seventy-two
extra-uterine cases, but they had not been looked for before the publication of
Sampson’s first paper. Sterility was very common, but complaint of severe
dysmenorrhoea had only been made by about one quarter of the patients. The
commonest complaint made was that of abdominal pain, and he had been struck
with the frequency with which it was associated with nausea and vomiting. He
asked if this association had been noted by others. There was little doubt that
radium could cure adenomyoma, but the practical difficulty lay in the differential
diagnosis between ovarian growths of this nature and chronic inflammation of the
adnexa.

Graves’ Disease and Thyroid Instability in the Cow, and its
Relation to Ovarian Disease.

By L. P. Pugh, B.Sc.Lond., F.R.C.V.S.

Introduction.

Observations extending over some years have at length led the writer
to the assumption that the so-called “ nymphomania ” of cows is merely
one phase of a process which is in its entirety analogous to the hyper-
thyroidism-myxcedema syndrome in the human species. But to establish
this thesis is a matter of no small difficulty. The symptom most readily

Section of Obstetrics and Gynaecology

discovered in cows, i.e., the sexual excitement, may be carefully concealed in
human beings. On the other hand the vascular changes which can be readily
studied in man are not easy and often impossible to elucidate in animals.
These very facts make the task more urgent, since here is an obvious example
(if the thesis be proved) of the great mutual assistance which veterinary and
human pathology may afford each other. Study of this subject has naturally
opened up more lines of inquiry than the mere identification of the two
diseases, but in this paper it is proposed to advance and support, however
inadequately, the following propositions, namely :—

(1) That “ nymphomania ” in cows is a part of a constitutional disorder
known in human pathology as Graves’ disease.

(2) That disorder of the thyroid function is an essential feature of the
“nymphomania” syndrome.

(3) That this disorder is profoundly influenced by ovarian disease.

It is impossible in cows, and, as the writer imagines, difficult in human
beings, to separate with certainty the symptoms of hyperthyroidism from those
of myxoedema. It is true that at one time physicians saw Graves’ disease as
one well-defined syndrome and myxcedema as another. Later, these were
found to be much more closely connected than had hitherto been considered
probable. Later still the conceptions of hyper- and hypothyroidism have
extended into an ever-widening sphere until the original clear-cut syndromes
have begun to be obscured by the results of clinical and experimental observation.

Thus it comes about that nymphomania in cows cannot be presented as a
syndrome due to the disorder of a single endocrine gland but rather as a disturb¬
ance of that endocrine balance which we call good health, a balance to which
each organ contributes its proper share of some specific secretion. There are
indeed many such disturbances, nor can we say with certainty which gland is
primarily at fault in each of them. But from many which are known we pick
out Graves’ disease in man and nymphomania in cattle because they are seen
to have so many features in common that their comparison seems likely to be
the most fruitful line of research in approaching the many problems which
await solution in endocrinology and in practical therapeutics.

When we speak of Graves’ disease that name must be considered to apply
to the whole symptom-complex of which a portion was first described by Parry
in 1825, then by Graves in 1835, later by Basedow in 1840, while a further
portion was described by Sir William Gull as a cretinoid condition and by Ord
as myxcedema. In dealing with this whole syndrome it is important to keep
in mind the fact that hyperthyroidism does not progress gradually and in an
orderly manner to the other extreme of myxoedema. An infinity of phases
divide the two and in these sometimes hyperthyroidism, sometimes hypo¬
thyroidism appears to predominate. Moreover there are effects of hyper¬
thyroidism which do not immediately pass away when hypothyroidism gets
the upper hand and so also there are signs of myxoedema which may persist
through a subsequent phase of hyperthyroidism. In an early case the picture
maybe comparatively simple, but in one of long standing the clinical appearances
may be complicated not only by the varying effects of previous phases but by
the predominance of symptoms referable to other endocrine organs the impli¬
cation of which is secondary.

The Clinical Picture of Graves’ Disease.

The signs and symptoms of Graves’ disease are conveniently summarized
by the late Dr. T. D. Savill [l] whose “ System of Clinical Medicine ” is

94 Pugh: Graves’ Disease and Thyroid Instability in the Cow

quoted not because his authority is greater than that of other writers but because
he was more concerned to crystallize the essentials from the very extensive
literature on this subject. Dr. Savill summarized the following five chief
groups of symptoms:—

(а) Cardiovascular .—Including palpitation, increased frequency and tumultuous
heart action, paroxysmal dyspnoea, cardiac murmurs, sometimes dropsy and
albuminuria.

(б) Nervous .—Including nervousness, irritability, insomnia, depression alternating
with excitement, mania, vertigo, hallucinations, tremor, sudden perspirations, loss of
hair and diarrhoea.

(c) Thyroid Enlargement —Variable but always present at some stage. Mechanical
effects of thyroid enlargement, such as change of voice.

(d) Exophthalmos. —Present in varying degree though sometimes not until late in
the disease.

(e) Disturbance of General Health .—Progressive weakness.

Savill does not mention wasting, but that this is a characteristic feature is
acknowledged by most writers. He gives the following additional facts :—

(/) Upwards of 95 per cent, of cases are females, a large number young adults
between the ages of 15 and 80.

(g) Heredity has not been traced but hereditary neuroses are commonly present. 7

(h) Fright, anxiety, love affairs, and mental overwork are potent factors in deter¬
mining the disease.

The same writer details the following as the chief characteristics of
myxcedema:—

(а) Weakness of very gradual onset with characteristic slowness of action, Ac.

(б) Puffy, immobile, vacant face with flushed cheeks. Scanty hair. Brittle nails.

(d) Intolerance of cold. Dry, scaly skin, slow pulse.

From the foregoing quotations we can obtain a sufficiently accurate idea of
the main symptoms of the hypo-hyper-thyroid syndrome, but before proceeding
to a detailed comparison with nymphomania I will indicate the chief features
in a typical case of the latter disease.

The Clinical Picture of Nymphomania.

The disease is most commonly met with in pedigree herds, the individuals
comprising which are commonly of a distinctive nervous temperament. In
some cases it is hereditary. The subject is always of the female sex and the
usually antecedent circumstances are pregnancy and heavy milking. Owing to
the habit of removing the calf from the mother, which is an essential if regret¬
table factor in the production of milking records, the emotional stress occasioned
by these circumstances is exceptionally severe. Those who have heard the
continuous cries of the cow from whom the calf has been removed will be able
to form some estimate of its severity.

Early stages of the disease most frequently seen during the latter half of

i The writer is informed by Dr. Gordon Ward that he has under his care at the present time
two families in which mother and daughter have been affected with exophthalmic goitre.

Section of Obstetrics and Gynaecology

pregnancy seldom come under the observation of veterinary surgeons and when
the stage of nymphomania is reached the chief symptoms of hyperthyroidism
have been established for some time. The animal is excitable, nervous and
even maniacal. The sexual phase known as oestrum becomes continuous and
the animal will ride others and even inanimate objects. The symptoms are
further aggravated by the presence of a bull. This stage, the “ nymphomania ”
of text-books, is of several months* duration in an average case and often
terminates in the slaughter of the animal, since it is no longer of use for
milking or breeding purposes. At this stage there can always be found
follicular ovarian cysts and rupture of these will ameliorate the symptoms.
In the next stage the cow begins to assume male characteristics. The voice
changes, there is thickening of the neck and alteration in the shape of the
trunk together with other signs which will be described later. The last stage
is one of lethargy and slow pulse, a condition in which the results of previous
stages still remain, but no longer progress. Although these stages are described
in their most usual order, it is to be remembered that any individual case may
be difficult to assign to a particular stage and that the progress is rather a
swing backwards and forwards with a prevailing general tendency to myx-
oedema than an ordinary process such as we have described.

We now return to our thesis: That “ nymphomania " in cows is a part of
a constitutional disorder known in human pathology as Graves' disease.

To establish this it is necessary to compare the symptoms in fuller detail.
It must be explained that every attempt has been made to procure specimens
for histological examination. Some have been obtained, but only with very
great difficulty, notably from one case of very long standing in which the
thyroid was obviously fibrotic. But the specimens are so few and there is so
complete a lack of normal standards in cattle that the case must for the present
stand or fall on clinical grounds. In any case it is not claimed that this paper
can do more than afford a basis for future inquiry.

Comparison op Graves' Disease and Nymphomania.

Age and Sex Incidence .—In both, the victims are predominantly females at
the fertile period of life. This predominance is 95 to 5 in human beings [l]
and as much or more in cattle. No case has yet been described in a bull but
it may be remarked that bulls have a limited commercial value and find their
way to the market at an early age. There may be one bull to twenty cows in
the country at any particular time. Moreover the bull is not exposed to the
stresses incidental to heavy milking and pregnancy but on the contrary is kept
quiet and secluded. Finally, it may be noted that diagnosis would be extremely
hazardous. For all these reasons we may have to wait some time for a
description of the disease in the male sex in cattle.

Breed and Heredity .—Both occur typically in individuals of “ thorough¬
bred " temperament. The writer knows of the disease in three successive
generations in cattle and is informed of hereditary cases in human families.
Whether it is more than inheritance of temperament may be open to doubt,
but, on the other hand, it may also be doubted whether temperament is
anything more than an expression of the endocrine balance in individuals.

Exciting Causes .—In the human disease exciting causes seem to operate
mostly through the nervous system. At first sight we may hardly expect to
find an analogy with these in cattle. But the distress of the mother after
removal of her calf must be admitted to be a frequent antecedent and to be an
emotional shock greater than falls to the lot of most human cases.

96 Pugh: Graves' Disease and Thyroid Instability in the Cow

Cardio-vascular Symptoms. —The writer has been able to satisfy himself
that the typical tumultuous action of the heart, which may even be audible at
a distance, is present in cows as in human beings during the early stages
of the disease. Tachycardia accompanies it. It is not possible to identify
palpitation in cows, nor have dropsy or albuminuria been noted—but these are
not common in any case.

I have under my observation at the present time a cow that developed
nymphomania eighteen months ago. She recovered quickly at the time from
the sexual mania, but is still affected with tachycardia and extreme nervous
irritability.

Nervous Symptoms .—On general grounds the similarity between the two
diseases is exact. In both cases we have extreme irritability and excitement
with mania as an occasional denouement . In Graves' disease tremor is most
apparent when the hand is held out, or held in such a way that no steadying
weight is thrown upon the limb. These circumstances do not occur in cattle.
I have noted a fine skin tremor presumably due to the underlying muscles
which may be analogous to the tremors seen in Graves’ disease. Diarrhoea is
seen in cattle during the early stages, a cow often having frequent evacuations
if a stranger appears, or from other slight cause. This reflex is under closer
control and is naturally less apparent in human beings but has nevertheless
been recognized and mentioned in the literature, e.g., Savill [l], already quoted.

Thyroid Enlargement. —This is not an invariable feature in women but
is usual, and is easily seen since the gland is not deep seated. In the cow it is
deep seated and consequently it is difficult to appreciate changes. We have no
evidence either way that it is enlarged or not enlarged. This makes it doubly
unfortunate that no histological reports are available.

Exophthalmos .—This has been observed in the early acute stage of nympho¬
mania and is common in Graves’ disease. The eye of the cow is normally
somewhat exophthalmic, which makes this sign less easy to detect unless one
is on the look-out for it.

General Health. —In both diseases failure in this is of the same character,
wasting being the most prominent feature.

Myxcedema as a Sequel. —This is well known in Graves’ disease and
advanced cases of nymphomania present similar symptoms. The hair becomes
dry and harsh, the disposition extremely lethargic and the pulse slow. I have
been able to satisfy myself as to thickening of the skin but this is naturally
less apparent in a normally thick-skinned and hairy animal. The animal
becomes constipated. The above parallels between the two diseases amount
almost to identity. In each case there is a stage of excitability (the detailed
symptoms being in many cases identical) followed by one of lethargy, mental
and physical. In both conditions there is an extraordinary type of heart
action which is typical and which is by universal consent associated with
thyroid hyperactivity. Both present the highly characteristic age, sex and
temperament incidence and in both there are the possible terminations, namely,
cessation of the disease or steady progress to a state of lethargy. That the
parallel may be more complete it may here be noted that the administration of
thyroid extract has in each case the same effect, namely, amelioration of the
hypothyroidism symptoms.

My opinion is that the evidence already produced is sufficient to establish
a degree of clinical identity which goes far to justify the thesis already put
forward, namely, that nymphomania and the Graves’-myxoedema syndrome
are essentially the same. It will now be assumed that this is true for the

Section of Obstetrics and Gynaecology

purpose of considering the following symptoms, which are of much greater
interest and importance when regarded from this point of view, namely:
(1) Sexual excitement—nymphomania as a symptom ; (2) pelvic and ovarian
disorder; (3) assumption of male characteristics.

Nymphomania as a Symptom .—CEstrum in the cow normally lasts for
about twenty-four hours. It seems to coincide with the final period of ripening
of an ovarian follicle and is certainly brought to a conclusion by the rupture of
a follicle whether natural or artificial. I have several times terminated oestrum
in this way. The first sign of nymphomania is commonly a lengthening of the
cestral period, perhaps to three or four days. This attracts the attention of
the herdsman and if a veterinary surgeon be consulted he will invariably
obtain the history that the cow has been one of exceptionally nervous
disposition. This history is best obtained by suggesting the contrary, which
will be denied. At this time it is always possible to find an unruptured follicle
and if this be ruptured per vaginam oestrum terminates and the animal may
return to the normal state or may suffer from a recurrence of symptoms
associated with delayed bursting of the follicle at the next oestral period.
A repetition of artificial rupture on two or three occasions will not uncommonly
restore the animal to normal health. Failing any treatment oestrum is further
prolonged until it becomes practically continuous and the associated symptoms
increase in severity. The excitability becomes extreme and the disease,
' nymphomania,” is fully established.

It does not seem that there is any human parallel to these symptoms, but
it has to be remembered that no such parallel has been sought for, and that
for social reasons any such symptoms would be kept in the background.
The cow does not undergo the years of training which prompt women to
suppress manifestations of sexual desire. The result is frank and obvious
nymphomania. We cannot expect to see such symptoms in subjects of
Graves’ disease, nor, in fact, do we find them mentioned in the literature.
Geikie Cobb [2] says, “ Perhaps the saddest of the changes wrought by this
disease are the changes for the worse in the psyche,” but the exact intention
of this remark is not certainly evident. It may be that gynmcologists can
throw some light on the question. Certainly hyperthyroidism is associated
with the attainment of puberty and also with pregnancy, so that we might
well expect psychic change associated with changes of a physical nature.
But beyond this we cannot go at present.

Gynaecological Disorders.

Pelvic troubles are extremely frequent in cows, occurring perhaps in 40 per
cent, in the form of metritis, cervicitis, &c., and are all of a definitely septic
type. Such pelvic troubles may of course complicate nymphomania, but they
are not sufficiently constant to suggest that they have direct mtiological
significance. A constant pelvic abnormality in nymphomania is patency of
the cervical canal together with a relaxation of the vaginal tissues. If the
cow has calved there is added definite subinvolution of the uterus. The
second and most striking abnormality is the invariable existence of ovarian
cysts. These are always follicular in origin, and originate in ripened but
unburst follicles. That they are closely associated with the nymphomania is
evidenced by the cessation of the latter if they be ruptured or removed by
ovariotomy. Their exact mode of action cannot be understood without
advancing into the debateable fields of endocrinology, and to do this would
unduly enlarge the scope of this paper.

Jy-0b 2 *

98 Pugh : Graves' Disease and Thyroid Instability in the Cow

Very few figures seem to be available with regard to pelvic lesions in
Graves' disease. Helen Gurney [7] states that in 8 per cent, of cases there
was “ disturbance of the generative function ”; in 15 per cent, there was
amenorrhoea ; 6 per cent, of the cases developed after miscarriage. These
figures are neither very definite nor very satisfactory. In a case published by
Ward (the reference is unfortunately not obtainable) both ovaries were cystic,
and it is probable that isolated cases of the sort might be disclosed by a more
thorough search of the literature than active country practice of a profession
allows. But at present there is no real information available either as to the
existence of nymphomania or of pelvic lesions.

There remains for discussion under this heading a pelvic lesion of quite
different character, i.e. t actual pelvic deformity and at times multiple fractures.
There would appear to be at least two factors present, namely, slackness of
ligaments and softening of bone. The photographs show the resulting clinical
characteristics, the most important of which is the elevation of the root of the
tail. This would seem to be due to a rotation of the pelvis on the line joining
the acetabula. That the change is due to ligamentous relaxation is strongly sug¬
gested by the fact that it disappears under appropriate treatment, whereas bony
changes would remain. Relaxation of ligaments is symptomatic rather of
myxoadema than of hyperthroidism. Geikie Cobb [3], in connexion with the
human disease, says that he is “ certainly of opinion that the relaxation of
the ligamentous structures in submyxoedema is something more than an
artificial symptom. He has noticed it in a number of patients affected with
the disease in which the diagnosis was confirmed by treatment. There are
certain other signs of ligamentous relaxation which have been noted in cows,
e.g., “ rheumatic ” joint sounds, slipping of the patella, and partial eversion
of the vagina. It is possible that similar signs might be found in human
beings.

Multiple fractures of the pelvis do not seem to have any parallel in
myxoedema. One is naturally inclined to suggest that they are due to excessive
decalcification in the hyperthyroid stage, but there is no direct evidence of
this. Little is known about these fractures beyond the fact of their
occurrence.

Assumption of Male Characters .—This is a very striking characteristic of
the middle stages of nymphomania. The nervous irritability of the earlier
stages give place to a certain aggressiveness, and the cow will paw the ground,
kick out with its forelegs, and charge other animals or its attendants. The
voice changes to the deep note of the male sex. The appearance of the head
changes together with the expression, and the neck grows thicker. Even those
who are inexpert in veterinary matters frequently comment on the change. The
female characters regress. The mammary gland atrophies, while the clitoris
is often enlarged. The general appearance is well shown in the photographs
exhibited.

These remarkable changes do not seem to have any complete parallel in
myxoedema, but there is a partial parallel in the loss of many attributes of
femininity. It is usually allowed that the anterior portion of the pituitary
becomes more active as the thyroid activity fails. But as a rule this is not
sufficient to give rise to symptoms of hyperpituitarism in women. Swale
Vincent [5] sums up the matter as follows: “ When the pituitary hyper¬
trophies as a result of subthyroidism, there are no symptoms of super-
pituitarism, so that the pituitary as a whole does not become more active."

On the other hand, the increasing ovarian activity that accompanies the

Section of Obstetrics and Gynaecology

subthyroidism (especially when full sexual indulgence is allowed), undoubtedly
stimulates the anterior lobe of the pituitary. But beyond the assumption
of male characteristics, there are no other indications suggestive of
acromegaly.

There are certain reasons for supposing that the thyroid-pituitary balance
in cattle is not of quite the same order as in man. It is. a fact (and to this
Swale Vincent [4] also calls attention) that adult herbivora can support life
quite well without their thyroid glands ; this might perhaps be interpreted as
meaning that adult herbivora lose their thyroid at the close of the fertile
period of their lives. Cases of nymphomania have not yet reached this-
stage, but there is no doubt that this disease quickly renders them sterile, and
that exhaustion of the thyroid seems to supervene much more speedily and
completely than in man. One is consequently not very surprised to find that
actual signs of hyperpituitarism dominate the clinical picture in cows, but
are relatively little obvious in human beings. But this again is an excursion
into endocrinology which may be thought out of place in a purely clinical
picture.

Conclusions.

(1) The foregoing details appear to substantiate the thesis that the so-called
nymphomania of cows is a part of the Graves-myxcedema syndrome, the
phase of sexual excitement probably marking the passing over from the
hyper- to the hypo-active stage of the thyroid. (In this connexion it is
interesting to recall Colonel McCarrison’s [6] written query at a recent
discussion on Graves’ disease: 11 Has suppressed excessive or perverted sexual
function anything to do with its onset ? ” From a purely clinical point of
view, excessive coitus in an affected animal tends to force it more quickly into
the hyperthyroidic state thaa the reverse.)

(2) It is further obvious that the whole syndrome from hyperthyroidism
to myxoedema can be passed through much more quickly in cattle, and is in
many ways more easy to study, since the life of a cow may be terminated
at will.

(3) For the cattle breeder and the owner of pedigree herds the subject has
great importance, because nymphomania leads to sterility, and thus to great
commercial loss.

(4) Nevertheless the subject cannot be studied as it should be except on an
experimental farm with proper laboratory accommodation, and it is to be hoped
that someone to whom these facilities are available will devote the necessary
attention to the subject.

REFERENCES.

r l ] Savux, “System of Clinical Medicine," 5th ed., pp. 219-223. [2] Cobb, Geikie, “The

Organs of Internal Secretion," 3rd ed., p. 170. [3] Ibid., p. 106. [4] Swale Vincent, “ Internal
Secretion and the Ductless Glands," 2nd ed., p. 319. [5] Ibid., p. 400. [5] McCarrison,

Discussion on Exophthalmic Goitre (British Medical Association Annual Meeting), see Brit. Med.
Joum., November ll, 1922, p. 913. [7] Gurney, Helen M., Brit. Med. Joum ., 1915, vol. i, p. 924.

[N.B.—The photographs of cows illustrating this paper have been bound
and are kept in the Library of the Royal Society of Medicine for reference.]

100 Pugh: Graves? Disease and Thyroid Instability in the Cow

Professor Swale VINCENT, commenting upon the importance and originality of
Mr. Pugh’s work, said that the pathology of the disorder could not be regarded as
beyond dispute until the thyroid had been studied histologically at different stages.
Mr. Pugh, had, however, put forward a very good case for the thyroid. The diagnosis
of disease of the ductless glands, especially in minor degrees of derangement, was
notoriously difficult. When two or more glands were involved and interrelationships
had to be borne in mind, the complications introduced placed the problems practically
beyond our powers of analysis in the present state of our knowledge.

Section of ©betetrlce ant> Ovnaecoloav

President—Dr. T. W. Eden.

Sarcoma in an Ovarian Dermoid Tumour.

Shown by Herbert E. Spencer, M.D.

L. S., AGED 41, married but never pregnant, was admitted to University
College Hospital, on December 8, 1915, complaining of discomfort from piles,
constipation, and a feeling of weight in the rectum. Menstruation began at
the age of 15, was regular, rather profuse, of seven days' duration. There was
some frequency of micturition.

The patient was rather thin, the breasts and nipples small. The tongue
was furred, the temperature 99° F., the pulse 104. All the patient’s teeth
were artificial. Nothing abnormal was detected in the chest. By palpation
of the abdomen an indefinite tumour could be felt on deep pressure in the
pelvic brim. Two piles protruded from the anus.

On vaginal examination the uterus was normal in size, but was pushed
forwards by a tumour as big as a double fist. The tumour, wedged in the
pelvis, felt as hard as a uterine fibroid ; but at its lower end was a softer
nodule, as big as half a large grape, which projected from the main outline of
the tumour. It was thought that the tumour was an ovarian fibroid. There
was no free fluid in the abdomen.

The tumour, which affected the left ovary, was removed entire by laparo¬
tomy, on December 11, 1915. There were no adhesions. The pedicle was
tied with silk. A small sessile fibroid of the size of a pea on the anterior wall
of the body was not removed. The wound was closed by through and through
stitches of silkworm gut, buried silk (continuous for the peritoneum and
interrupted for the fascia) and horsehair for the skin. The right ovary and
tube were normal and were not removed. A large pile was removed by the
cautery clamp. The operation lasted thirty-five minutes.

The patient made a good recovery. The highest temperature was 100*4° F.,
on the night of the operation. The wound healed by first intention and the
patient left the hospital on January 5, 1916, weighing 6 st. 10 lb. On
January 15, she weighed 7 st.

On February 15 the uterus appeared to be slightly enlarged; but no
tumour could be felt on abdominal and vaginal examination. On March 28
she complained of colicky pain in walking; her weight was 7 st. 5 lb.

On May 16 she still weighed 7 st. 5 lb. and felt well. No tumour could
he felt in the abdomen or pelvis. On July 11, she complained of pain in the
left lumbar region; but no definite tumour could be felt. After this date I did
not see her again; but I heard from her doctor that the abdomen increased

S—Ob 1 [June 7, 1923.

102 Spencer: Sarcoma in an Ovarian Dermoid Tumour

in size and several tumours became palpable in the abdomen, the largest being
in the left lumbar region. She rapidly became weaker and died cachectic
on November 16, 1916.

The tumour is a cyst of the left ovary, of flattened oval shape, measuring
in. by 3± in. by 3 in. and is smooth on the surface, over which several

FiO. 1.—Showing the outer surface of the tumour. Of the two rounded
prominences below, the right is a dermoid, the left a sarcoma. Four smaller
sarcomata are seen on the surface ; two of them have been incised. (Natural size.)

vessels are seen coursing. The cyst wall is thin and translucent. The
contents of the cyst were partly fluid and partly solid; the latter, looking
like fat globules through the cyst wall, in the fresh state could be seen to
float about when the cyst was shaken. On opening the cyst the contents

Section of Obstetrics and Gynaecology

103

were seen to be particles of sebaceous material of various sizes floating in a
turbid watery fluid. The particles were not rolled into round pill-like bodies.
There was no mass of hair in the cyst, but two hairs were found growing
from its inner wall.

Fig. 1 is a drawing of the outer surface of the tumour. The Fallopian tube

FlO. 2.—Showing the inner surface of the other half of the tumour (not the half
shown in fig. 1). Of the two adjacent tumours seen on section below, the white growth
on the right is the embryonic process in a dermoid cyst, the grey tumour is sarcoma.
Above is another small loculus in the wall partly filled with sarcoma. (Natural size.)

is seen below with two small Kobelt’s cysts. Below this are two small ovoid
prominences seen in section in fig. 2. Of these that on the right is a
dermoid, that on the left a sarcoma. Four other small growths are seen on
the surface: the uppermost and largest of these and the lowest (just beyond

104 Spencer: Sarcoma in an Ovarian Dermoid Tumour

the edge of the tubal fimbriae) have had sections removed to show their
solid nature (sarcoma). The inner surface of this half of the tumour also
was smooth and showed no solid growth ; but there were two hairs about 4 in*
in length growing from the inner surface near the line of section. They are

of course not shown in the drawing and were the only hairs present.

Fig. 2 is a drawing of the inner surface of the other half of the tumour

(not the half drawn in fig. l). It shows the thin wall with a few vessels

coursing over its inner surface. Growing in the wall, apparently in definite
loculi, are three tumours, the lower two in adjacent loculi. Of these two,
that on the right is the embryonic process of a dermoid attached on its deeper

Fig 3.—Large round-cell sarcoma in ovarian dermoid tumour. (Low power.)

surface and lying in a thin-walled cavity somewhat larger than itself and
surrounded, except at its base, by a narrow space which was filled by sebaceous
material. The darker tumour on the left is a sarcoma, and the smaller
tumour at the upper part, which only partly fills the loculus, is of the same
structure.

Microscopic Structure.

(4) Of the Main Cyst .—The presence of sebaceous material and of two
hairs growing from its inner wall shows this to be a dermoid. Sections cut
from different parts show only a thin fibrous wall lined by a single layer of
atrophied flat epithelium. No sebaceous glands or hairs were found in the

Section of Obstetrics and Gynsecology

105

sections cut, and to demonstrate them microscopically would spoil the specimen
for museum purposes.

(B) Of the Cyst containing the Embryonic Process. —The outer wall has
the same structure as the main cyst: the embryonic process is covered with
keratinized stratified epithelium and its substance consists of fibrous tissue and
fat with a few sebaceous glands and hairs. There is no sarcoma in it.

(C) Of the Solid Growths. —Four of these have been cut and all show the
same structure. The growth is a large round-cell sarcoma with slight small
round-cell infiltration. There are a few vessels, some thin-walled and some
well developed (see fig. 3). In some sections a few giant-cells are seen; these
are not shown in the drawing.

Ruptured Unilateral Solid Cancer of Ovary : Ovariotomy ; no
Recurrence Six Years later.

By Herbert R. Spencer, M.D.

A. M., AGED 37, married, who had had one daughter nine years ago, was
admitted to University College Hospital on January 4, 1917, complaining,
for two months, of swelling of the abdomen which had suddenly increased
three days before admission after an attack of sudden sharp pain. She had
been anaemic for two years. Menstruation had begun at the age of 13, was
regular every twenty-eight days, lasted five days and was (before her marriage)
accompanied by severe pain in the abdomen. For the last two months the
periods had lasted two weeks and between the periods there had been a slight
bleeding, but no other discharge. There was no history of tumour in the
family.

On examination the patient looked pale and ill and the skin had a slightly
yellow tinge. The pulse was 136. The blood-count on January 4 showed:
Bed cells, 2,600,000 ; haemoglobin, 50 per cent.; colour index, 0*9 ; total white
cells, 32,000; small lymphocytes, 5 per cent.; large lymphocytes, 2 per cent.;
transitional, 1 per cent.; polymorphonuclear neutrophils, 92 per cent. The breasts
were flaccid and showed no sign of pregnancy. An ovoid tumour reached up
to an inch above the umbilicus. It had a fleshy consistence, as if it were
a tense cyst filled with blood. The cervix pointed forwards and admitted the
finger for 1 in. Nothing could be felt through it. The uterus was retro-
verted, apparently slightly enlarged, freely movable. In front of the cervix
the lower end of the tumour could be felt high up and movable. The diagnosis
was ovarian cyst with haemorrhage into it.

The tumour (left) was removed on January 6 , 1917. A large quantity of
bloody fluid was found in the abdomen. The tumour was blue-black in colour,
of the shape of a large ovary, measured 9 in. by 6 in., narrower at the inner
end, in consistence like a spleen. On the surface at the inner end was a
rupture 4 in. long exposing the tissue of the tumour which was infiltrated with
blood and could be easily pulped by the fingers. The tumour was removed
unopened, the pedicle, which was twisted half a turn, tied and the raw surface
stitched over with silk, and the wound closed with through and through
stitches of silkworm gut, fine silk (continuous for the peritoneum and
interrupted for the sheath of the rectus) and silkworm gut and horse-hair
for the skin. The operation lasted forty-two minutes.

The wound healed by first intention and the patient left the hospital quite

106 Spencer: Torsion of Pedicle of Ovarian Tumour

well on January 31, 1917, when the uterus and the right ovary (which
appeared to be quite normal at the operation) were found to be freely movable.
I saw the patient every year till June 21, 1920, when she was quite well, and
the uterus and right ovary appeared normal. At bhat time she lost a good deal
at the periods, using seven or eight diapers the first day.

I examined her on May 16, 1923, six and a quarter years after the
operation, when she was in excellent health and menstruated normally.
The uterus and right ovary were of normal size and freely movable and the
abdominal scar was sound.

Microscopic Examination. —The tumour is a medullary carcinoma consisting
of masses and tracts of epithelial cells of polygonal shape set in a fibrous
stroma which for the most part forms narrow bands, but in places forms
considerable tracts. There is extensive congestion of the stroma and haemor-
rhages occur both in the stroma and in places in the epithelial masses. In the
central parts of some of the larger masses are cystic spaces filled with d6bris.
The haemorrhages are no doubt due to the torsion of the pedicle. There is
very little small round-cell infiltration.

Remarks. —This case, except that the tumour is larger, exactly resembles
a case of ruptured medullary cancer of the ovary which I published in the
Proceedings of the Royal Society of Medicine , 1915, viii (Section of Obstetrics
and Gynaecology), p. 61. In that case also only the affected ovary was
removed and the patient subsequently had two children and was quite well
seven years after the operation.

Stretching of the Epithelium of the Tubal Rugae by Blood
effused into them in Torsion of Pedicle of Ovarian Tumour.

By Herbert R. Spencer, M.D.

TORSION of the pedicle of an ovarian tumour is well known to cause
infiltration of blood into the tissues of the tumour, the broad ligament and the
Fallopian tube. It is also well known that the shape of the epithelium in
cysts and glands in various parts of the body is modified by the pressure
to which the cavity is subjected, columnar epithelium being changed to
cubical or flat epithelium according to the amount of pressure. Alteration
of the shape of the epithelium by pressure (from effused blood) outside the
cavity of the Fallopian tube, which is new to me, is shown in the specimen
exhibited. It was removed on July 2, 1920, together with a multi-locular cyst
with twisted pedicle, from a lady aged 51, who made a simple recovery and
was quite well two years later. The patient had had several attacks of pain
in the abdomen and was very ill (temperature 100° F., pulse 100) with partial
intestinal obstruction, owing to adhesions, on her arrival at the nursing home.

The tumour, a universally adherent multilocular cyst weighing 3£ lb.,
was removed whole. It presented the usual black-red appearance owing to
infiltration of blood: the contents and lining of the cysts were also blood¬
stained and in some of the smaller cysts there was clotted blood.

The Fallopian tube was thickened, especially at its ampullary portion,
where it was nearly $ in. in diameter and dark red from congestion: the
fimbriae were also thickened and congested, the abdominal ostium patent.
One inch from the abdominal ostium a pedunculated Kobelt's cyst (or

Section of Obstetrics and Gynaecology

107

accessory tube) of the size of a small pea was attached by a short band-like
pedicle. ^ m. in diameter, just below the Fallopian tube. A transverse section,
magnified six diameters, through the Fallopian tube and the Kobelt’s cyst
is shown injfig. 1, drawn with the aid of a camera lucida by Mr. Ford. Above

and to the left is seen the section of the Fallopian tube, below and to the right
the Kobelt’s cyst; between the two is the mesosalpinx extensively infiltrated
with blood.

The KohelVs cyst (? accessory Fallopian tube) shows two rugae, the

108 Spencer. Torsion of Pedicle of Ovarian Tumour

epithelium of which is slightly altered by effused blood as described in
the Fallopian tube.

The mesosalpinx shows vessels distended with blood \vhich is also
infiltrated into the tissues. Four parovarial tubules are shown ; but, under
a high power, seventeen can be counted and they are found to be surrounded

by bundles of unstriped muscle. The epithelium of the tubules is of low
columnar or cubical shape : in one case the cells fill the lumen.

The Fallopian tube is seen to be filled with several masses which are rugae
extensively inliltrated with blood. It is shown as seen under a 1-in. objective
in fig. 2. Some of the rugae are covered with columnar epithelium, others with

Section of Obstetrics and Gynaecology

109

normal epithelium at their bases, but with cubical or flattened epithelium at
their extremities, where blood is effused. In some of the rug® the blood has
stretched the epithelium to such an extent as to flatten it like a vascular
endothelium.

Further research will be necessary to decide whether this is a common
occurrence in cases of torsion: in another case examined by me it had not
occurred. Perhaps it is the result of slight repeated torsion.

It seems to point to great elasticity of the epithelium of the Fallopian tube
and to its firm adherence to the subjacent tissue.

Carcinoma of a Prolapsed Cervix in a Woman, aged 77.

By Henry Russell Andrews’ M.D.

A little over thirteen years ago 1 I showed before the Section a specimen
of carcinoma of the cervix of a prolapsed uterus in a single woman aged 88,
treated by vaginal hysterectomy. I then commented on the fact that while
chronic ulceration of the prolapsed cervix was very common, carcinoma of the
prolapsed cervix was surprisingly rare. It was the first case I had seen. In
the discussion that followed Dr. McCann had said that he had never seen
carcinoma of the cervix with prolapse. Dr. (now Sir George) Blacker had
said that he had seen one case, and thought that “ in view of the important part
that chronic irritation had been shown to play in the production of carcinoma,
it was a most curious fact that carcinoma of the cervix was so uncommon in
cases of prolapse." To-night I am showing the only other case I have seen.

A multiparous woman, aged 77, was sent to me in May of this year (1923),
complaining of bleeding twenty-six years after the menopause. Sixteen years
ago she was given a pessary on account of prolapse, and wore it for four years.
For the last ten years she had worn a tight diaper to prevent the uterus from
coming outside. For twelve months there had been almost daily bleeding, at
first slight, lately more profuse. For five weeks she had been in bed on
account of the bleeding. The vaginal portion of the cervix was outside the
vulva, covered uniformly with red friable tissue, which bled readily. The supra¬
vaginal portion of the cervix was much elongated, and the atrophied body of
the uterus was situated comparatively high up. I thought she had carci¬
noma of the cervix, but as carcinoma with prolapse is so rare I cut out a
small portion for microscopical sections. The pathologist's report was :

Solid trabecular polygonal-celled carcinoma." The section is shown under
a microscope.

Vaginal hysterectomy was performed—a very easy operation in this case.
I had intended to repair the pelvic floor, but, at the request of the
anaesthetist, I finished the operation as quickly as possible, removing a good
deal of vaginal wall and packing the cavity lightly with gauze. The patient
made a very good recovery.

The uterus has shrunk so much that the elongation of the supravaginal
cervix is not well seen.

DISCUSSION.

Dr. ClTTHBERT LOCKYER agreed with Dr. Russell Andrews’ statement that carci¬
noma was rarely found associated with the major degrees of prolapse. He had never
seen a cancer of the cervix lying outside the vulva, but had operated for primary carci¬
noma of the vagina in a case of procidentia, and the specimen was preserved in the
Museum of the Charing Cross Hospital Medical School.

i Proceedings , 1910, iii (Sect. Obst. and Gyn ), p. 161.

110 Andrews: Prolapsed Cervix; Phillips: Dysmenorrhcea

Dr. T. W. Eden (President) said that he was not satisfied that a proper statistical
inquiry would show that the incidence of cancer of the cervix was less in women with a
severe degree of prolapse than in those in whom the cervix occupied its normal position
in the vagina. He could think of no reason why it should be less frequent in a
prolapsed uterus, and clinical impressions of frequency were often fallacious.

Dr. Andrews (in reply) said that he was still of the opinion, with all due deference
to the President, that carcinoma of the prolapsed cervix was much rarer than one
would expect, seeing that carcinoma of the cervix and prolapse were both common
conditions.

Mr. Victor BONNEY, M.S., read a paper on “ Diurnal Incontinence in
Women,” W’hich will be published in the Journal of Obstetrics and Gynaecology
of the British Empire .

The Treatment of Dysmenorrhcea : An Analysis of

100 Cases.

By Leonard Phillips, M.S., M.B., B.Sc.Lond., F.R.C.S.Eng.

This short communication is based on the treatment of 100 cases of
dysmenorrhcea without signs of organic disease. The treatment was conducted
almost entirely at the Women’s Hospital, Soho Square, and was chiefly non¬
operative. An effort was made to divide the cases into definite clinical types.
The subject matter falls conveniently into three divisions :—

(I) Interesting features of the case papers.

(II) The treatment in general.

(Ill) Discussion of four clinical types and their appropriate treatment.

(I) Interesting Features of the Case Papers.

(1) Occupation .—Practically always sedentary—typist, clerk, leatherworker,
machinist, &c.

(2) State .—Sixty-seven were spinsters, thirty-three were married, but all
the latter were sterile, though married for periods varying from one to sixteen
years.

(3) The Menstrual Loss .—Only a minimum had an average loss lasting
three or four days. Most were under three or over five days. More were
associated with excessive rather than diminished loss. Some had fortnightly
excessive loss, others intermittent menstruation. Menorrhagia was most
common, and was usually associated with a moderate degree of pelvic hypo¬
plasia, a condition of arrested development of the genital organs.

(4) Pain. —This was not at all constant in character, position or duration.
Sometimes iliac in position, sometimes hypogastric or sacral, it occurred
before, during or immediately after the flow, sometimes all three, and was
commonly associated with the passage of clots, the pain diminishing or
ceasing when the clots were passed. It was impossible to say that one type
of pain characterized the cases in regard to time of onset, duration, site or
character of the pain. Classification according to pain characteristics was found
to be impossible.

(5) State of Bowels. —In half the cases constipation was severe and con¬
stituted a definite complaint.

(6) Type of Patient. —The majority of the patients were poorly developed,
with weak abdominal muscles, faulty posture and breathing, anaemia or
visceroptosis.

Section of Obstetrics and Gynsecology

111

(7) Associated Symptoms.—Most of the patients had one or several of the
following symptoms: Headache, nausea, vomiting, frequency of micturition,
and sometimes diarrhoea.

(8) Pelvic Examination .—Rectal examinations were made on all unmarried,
and vaginal examinations on all married women. In rectal examination one is
able to reach beyond the bases of the broad ligaments and explore the pelvis
more satisfactorily than is often possible by vaginal examination, especially in
nervous women. In half the cases there were signs of arrested development of
the genital organs; a small acutely anteflexed uterus, or a small retroverted
uterus, with a short anterior lip to the vaginal cervix, and a short anterior
vaginal wall; poorly developed labia and breasts, and the male type of pelvis
and pubic hair. Though sometimes associated with scanty menstruation,
menorrhagia or fortnightly losses were far more frequent accompaniments. It
is not commonly recognized how common in the young adult female is this
association of dysmenorrhcea and menorrhagia with pelvic hypoplasia.

(II) Treatment in General.

(a) Fifty cases were treated with extracts of ductless glands either alone
or in combination with antispasmodics.

(b) Forty cases were treated with antispasmodics alone.

Only ten of the hundred failed to be relieved and eventually came to
operation.

Details of Treatment .—Fifty cases were treated by organotherapy. Extracts
of thyroid, corpus luteum, anterior lobe of pituitary, and mixed gland products,
were used separately and effectively. The majority were treated with
hormotone as follows :—

(1) Mist, cascara co. daily throughout the month.

(2) Hormotone, 1 tabloid t.d.s. for seven days before and during the
period.

(3) If unrelieved the following every three hours till relief was obtained (up
to four doses).

or—

Phenazone ...

Ext. caulophyilin liq.

Caffeine

Aq. chlorof—

15 minims
6gr.

1 oz.

Phenazone \

Aspirin f 4 gr. of each. Repeated three-hourly up to four
Pyramidon f doses in cases where pain was severe

Caffeine J

Sometimes Tinct. Belladonnae 5 minims was added to the above mixture, and
sometimes other antispasmodics such as benzyl benzoate were substituted.
Sometimes atrop. sulph. fhv gr. as a tabloid was used.

Forty-six of the fifty cases so treated were relieved. In some cases pain
was not abolished, but diminished, and in all the forty-six cases the patients
were enabled to work throughout the period in comparative comfort. Often
when the tabloids were omitted the painful periods returned, only to disappear
at the next period when the hormotone was re-administered.

The amount of relief obtained varied with the individual, but it was always
definite and in the majority of cases sustained. Of the forty cases treated with
antispasmodics alone, thirty-four were benefited, and only six came to opera-

112

Phillips : Treatment of Dysmenorrhoea

tion. Ten cases were treated between the periods with bromides and sali¬
cylates combined with laxatives ; and during the periods small nightly doses of
luminal were given. All were relieved.

In treating these cases an attempt was made to correlate and interpret the
available information and to evolve a plan of treatment based on the existence

of definite clinical types.

(III) Discussion of Four Clinical Types and their Appropriate

Treatment.

Clinical Type (1).

. Dysmenorrhoea is frequently a disease of faulty hygiene, upbringing and sur¬
roundings. A large proportion of these patients conformed to this definite type.
They were thin, anffimic subjects, poorly developed, with weak abdominal
muscles, absent abdominal breathing and faulty posture; they were consti¬
pated, had visceroptosis or a bad circulation, and followed sedentary lives with
little exercise and fresh air. Naturally in such cases the uterus is often
arrested in its development, and has a feeble musculature easily exhausted if
given much expulsive work to do. An exhausted muscle forced to continue
contractions gives rise to cramp and colicky pain, true alike of the heart, the
gastrocnemius and the uterus. Constipation necessarily has a bad influence,
for a mass of faeces in the pelvis acts very much as a pelvic tumour, increasing
congestion.

The Treatment of these Cases .—Often complete relief can be obtained by
improving the faulty conditions above outlined.

(1) Establish the correct Mental Attitude. —The patient must realize that
the period is natural and normal. She is not ill, and must bathe and take
exercise as usual, unless the pain is very severe.

(2) Correct Clothing .—No constricting garments likely to impede the pelvic
circulation should be worn, and stays (if worn) must not do the work of the
abdominal muscles.

(3) Correction of Constipation .—Plenty of water to be drunk, and fruit to
be eaten. Over-eating is bad, but enough food should be taken to give bulk to
the intestinal content. Exercise in the fresh air, abdominal kneading night
and morning, and an attempt to empty the bowels at the same time every day
should be aimed at. Purgatives only temporarily if possible.'

(4) Exercise and Exercises .—Light Indian clubs, tennis, hockey, walking.
The object is to increase the tone of the muscle in the abdominal wall, the
bowel, and the uterus, and by improving the general and local circulation
to produce improved nutrition and muscular development. Many patients do
not realize that the abdominal wall contains muscle. They allow their corsets
to do the work of the recti and obliques, inducing visceroptosis, constipation
and defective abdominal breathing. They must be taught: (1) To produce
hardening of the abdominal wall at will; (2) breathing exercises night and
morning before a mirror, standing in the correct posture; (3) exercises to
develop the abdominal muscles, such as lying flat on the back and raising the
body into the sitting posture, maintaining the legs and heels in contact with
the bed all the time. The patient’s leisure must not be spent in emotional
recreation, such as the theatre, kinema, or novel reading, but in walking or
exercising in the fresh air. Make this type of patient healthy and strong, and
as a rule the dysmenorrhoea is cured. It is not so common to see a robust girl
suffering from dysmenorrhoea. Too much emphasis cannot be laid upon the

Section of Obstetrics and Gynaecology

113

importance of faulty upbringing, surroundings and development, as a causative
factor in dysmenorrhcea, and the need of improving these as a first step
in treatment.

Clinical Type (2).

There is a type of dysmenorrhcea case in which the disturbance is
functional and allied somewhat to migraine. In addition to menstrual pain
these women complain of general rather than local symptoms. Headache
and nausea are common accompaniments of the pain. They are frequently
sensitive, nervous, worried women with eye-strain and constipation, and the
dysmenorrhcea is one symptom in a complex which Freud would have
designated as the expression of an unsatisfied desire, and which lately has
been described as an anxiety-neurosis. Whenever the general symptoms are
more marked than the local, general treatment is more likely to be successful.
Ten such cases in this series were treated successfully by sedatives as follows :
(1) Bromides and salicylates between the periods ; (2) luminal, 1 to lj gr., in
cachet or powder nightly during and just before the period ; (3) general
hygienic measures as already outlined, with attention to bowels and eyes.

Clinical Type (3).

There is a third type of case in which the symptoms and signs suggest
some form of obstruction as the chief causal factor. Though one of the earliest
aetiological theories of dysmenorrhcea, it has been abandoned by many, because
it is maintained that flexions and narrow canals cannot obstruct the flow of
one-third of a drop of blood per minute—the rate of flow, if 4 oz. of blood
is lost in four days. It has been shown that in cases of dysmenorrhcea a
sound can often be passed quite easily, whereas this may be impossible in
subjects without dysmenorrhcea.

But as a set-off against these arguments it must be remembered that in
cases of dysmenorrhcea the blood may not exist in utero as fluid but as clot,
when obstruction is possible even with a normal internal os and cervical canal.
We know that flat, thin casts are passed without pain, whereas solid rolled up
casts cause considerable pain.

Secondly, in some cases of dysmenorrhcea the pain diminishes or ceases
entirely when clots are passed, though intense pain exists before the clots
are passed.

Thirdly, the pain resembles ureteral and biliary colic in its intensity and
sudden onset, subsiding rapidly when the clots are expelled just as ureteral
and biliary colic suddenly subside when the stones are expressed into the
bladder or duodenum. Finally, though obstruction as a cause is decried,
gynecologists continue to employ cervical splitting operations such as anterior
hysterotomy, for the relief of pain, though it is reasonable to assume that
these operations are based on an obstructive view.

Fourthly, in three cases of hysterectomy for dysmenorrhcea (in this series)
performed during the menstrual period the uterus was found to contain clots.
Whether the intra-uterine clot is normal but is not dissolved because of some
endometrial defect, or whether clotting in utero is primarily pathological, are
problems which must be solved before the cause can be removed and the pain
cured by rational treatment. But it is reasonable to assume that a uterus
with poor musculature may be unable to expel rolled up casts or clots through
even a normal canal and os, without contractions which ultimately become
painful, ceasing when the solid body is expelled and the tired organ rests, and

114

Phillips: Treatment of Dysmenorrhcea

recurring once more when the uterus is again given the same task. It may be
that the imperfectly developed uterus, so commonly found in these cases,
is responsible in some way for the formation of the clot before expression or
for its failure of dissolution.

Clinical Type (4).

There is a type of patient who complains of pain in one or other iliac
region either alone or before the central pain, and in whom there exist signs
of arrested development of the genital organs . Menorrhagia is just as common
as scanty flow, because an undeveloped endometrium and musculature are
linked up with a normal ovarian stimulus. Often there is nothing in the
history to suggest obstruction, and clots may be absent. The obvious treatment
in 6uch cases is to stimulate development of the uterus, and this is often
successful in abolishing the pain.

In addition to the general hygienic treatment already outlined, good results
can be obtained in these cases by : (1) Organotherapy ; (2) electrical

treatment.

(1) Organotherapy. — Ovarian extract, corpus luteum, thyroid, anterior
lobe of pituitary, mixed gland (B. W. and Co.), and hormotone have each
been used. Why the latter should have proved the most valuable in this
series of cases it is difficult to say. It consists of extracts of ovary, thyroid,
pituitary and testis. We know that hypo-thyroidism, hypo-pituitarism, and hypo-
oophorism may all be associated with pelvic hypoplasia, a condition observed
in one-half of the cases in this series. It may be, that in a “ Gatling gun ”
prescription such as hormotone, containing all three extracts—one extract may
hit the mark where the others fail. By estimating the basal metabolism rate
it is possible to ascertain the existence of hypo-thyroidism even in the absence
of clinical signs, but moderate ovarian and pituitary deficiency may be more
difficult to determine, and herein lies the value of combined extracts. It is
interesting to speculate upon a possible part played by the extract of testis, for
this extract alone or in combination with extract of prostate is sometimes
successful in dysmenorrhcea cases.

Some years ago Bland - Sutton pointed out a histological resemblance
between the lining cells of the uterus and those of the large intestine. One
of the chief functions of the large intestine is absorption.

Arthur Thomson, in an admirable paper in the British Medical Journal ,* last
year, marshalled a formidable array of arguments in support of the view that
the endometrium is mainly absorptive in function. It has often been main¬
tained that seminal fluid is drawn into the cervix or body of the uterus and it
may be that such fluid is absorbed and exercises a beneficial influence on
genital development and conception. If this is so, it would throw some light
on the action of testicular and prostatic extracts.

(2) Electricity in Dysmenorrhcea. —Electro - therapeutists frequently use
electrical stimulation as a treatment for dysmenorrhcea. Gynaecologists, as a
rule, prefer a method of treatment which does not take the patient out of their
hands. A few of the cases in this series were benefited by electrical treatment,
not personally administered. High-frequency currents act by heating up the
deeply seated organs, so that there results : (1) Dilatation of the vessels;
(2) relaxation of spasm and inhibition of tone; (3) improvement in blood
supply and consequent improvement in nutrition and growth.

1 “ Problems involved in the Congress of the Sexes,” Brit. Med. Joum ., 1922, i, p. 5.

Section of Obstetrics and Gynaecology

115

Where an obstructive element is suspected relaxation of spasm can be
induced by intense currents over a short period. Where pelvic hypoplasia
exists, improved nutrition and development can be secured by less intense
currents over a longer period. Courses of electrical treatment sometimes
result in enlargement of the uterus, in disappearance of the dysmenorrhoea,
and in married women, in conception.

Of the ten cases in which medical treatment failed, two were cured by
curettage, and one by anterior hysterotomy. The latter is a very difficult
operation, as the cervix cannot be pulled down sufficiently as a rule.

Hysterectomy was performed in two cases. Histologically, both uteri
showed marked arteriosclerosis. The cavities, it was observed, contained clot.
The remainder—very severe cases—were sterilized by radium (100 mg. for
twenty-four hours).

A follow-up of 100 cases treated by operation was instituted as a com¬
parison with this series of 100 cases treated medically. It was found that
25 per cent, were cured, 25 per cent, relieved and 50 per cent, were unaffected.
The best results were in cases treated by curettage. The follow-up results
are certainly inferior to those obtained in this series of 100 cases treated
medically.

It is not suggested that the above figures are necessarily representative
of the usual results of surgical treatment, but I believe most gynaecologists feel
that the surgical treatment of dysmenorrhoea without physical signs is on the
whole disappointing.

DISCUSSION.

Dr. T. W. Eden (President) thought that this was an admirable piece of clinical
work, and the author deserved thanks for the patience and pertinacity with which he
had attacked this very difficult problem. To treat with success 90 per cent, of cases
of dysmenorrhoea by therapeutic measures only was a record of which Mr. Phillips
might well be proud.

Mr. Victor Bonne Y said he demurred at the frequency with which a develop -
mentally small uterus was diagnosed. In actual fact it was extremely uncommon to
find a uterus up which a sound could not be passed the normal distance, or to find, on
inspection through an abdominal incision, a uterus which was really small. Con¬
sulting-room methods of examination had very finite limitations. The really small
uterus was not infrequently associated with the most violent menorrhagia. He had
no case for or against organotherapy, but it was as well to remember that a number
of treatments had from time to time been vaunted as a cure for dysmenorrhoea.
Pioneers in a new treatment always seemed to achieve phenomenal success, which
unfortunately was rarely maintained by those that followed them. The late
Dr. Hennan’s advocacy of guaiacum as a cure for dysmenorrhoea was a case in
point. Mr. Phillips had, nevertheless, taken much pains in treating a very difficult
class of case.

Dr. H. Bussell Andrews said that Mr. Phillips’ very interesting paper con¬
tained many points for discussion, but there was not time to touch upon more than
two. He asked what w r ere the ages of the three patients treated by radium. Was
Mr. Phillips absolutely satisfied with the result of treatment in these cases ? Mr.
Phillips was to be congratulated on his high percentage of successes. He (Dr.
Andrews) thought that this was due to his patient treatment of girls with dysmenor¬
rhea for many months not only with drugs but with good advice with regard to
exercise in the open air, bedroom exercises, abdominal massage, and management of
the bowels. Improvement of the general health by these hygienic measures took time,
and most people were too impatient and advised operative treatment much sooner than
Mr. Phillips did.

116

Phillips: Treatment of Dysmenorrhcea

Dr. Evebabd Williams asked Mr. Phillips whether any cases of “ middle pain ”
were included in his series, and, if so, what had been the response to medical treatment ?
He also asked Mr. Phillips whether he had observed any marked difference in
response to organotherapy in these cases depending upon the age of the patient?

Dr. BRYDONE thought dysmenorrhcea occurred mainly in those backward in
development, but not from underfeeding. In his experience the large majority of
adolescent cases, or those aged under 22, got well, but over that age operative
treatment was eventually required. He ascribed the success of the many and
constantly varying treatments in some measure to suggestion, but could endorse the
success in treatment by pluriglandular extracts.

Mr. LEONARD Phillips (in reply to the President) said that one half of the cases
were associated with clinical conditions suggesting a moderate degree of genital
hypoplasia, 40 per cent., with the painful passage of clots, and 10 per cent, with
symptoms suggesting a functional origin. The majority of the cases required and had
hygienic treatment along the lines already mentioned. There was naturally some over¬
lapping in these types—but such a classification allowed of an attempt at rational
treatment. Sometimes the reaction of the patient was immediate and most surprising,
but sometimes six months elapsed before much improvement was noticed, and pro¬
longed and detailed treatment was absolutely essential.

In reply to Mr. Bonney, he stated that he was opposed to the operative treatment
of congenital retroversion associated with dysmenorrhcea. Operative replacement of
the uterus failed to cure the pain. He thought the tendency now was to regard these
small retroverted uteri in nulliparous women as of little significance as displacements,
but of some importance as conditions of arrested development. Treatment founded on
this assumption was more likely to be successful than operative treatment of the
displacement.

Dr Bussell Andrews had asked the age of the patients treated by radium, and the
nature of the results obtained. The women so treated were over 82 years of age, and
had received prolonged and unsuccessful treatment both medical and surgical; 100 mg. of
radium had been inserted into the uterus for twenty-four hours. The periods had ceased
entirely, and no pain had occurred since. The practice of using radium in the case of
young women carried with it the risk of inducing a subsequent sterility ; but in severe
and intractable cases of dysmenorrhcea this was a justifiable risk to incur if the
patient was already aware of it, and was willing to take it. Moreover,
dysmenorrhcea was associated with sterility in a fair proportion of cases.

Dr. Everard Williams wished to know if cases of middle pain were included, and
how the response to treatment varied with the age of the patient. No cases of
middle pain were included. The earlier the patient sought relief and the younger she
was, the better were the results obtained. The cases requiring operation were all
patients over 30 years of age, and who had been sufferers for years.

In bringing this subject before the Section, he had hoped that it would produce
a discussion from which interesting facts would arise, possibly of value in the treat¬
ment of this very common and distressing ailment. So little was known of its
pathology and so much still required to be done before a rational treatment could be
instituted.

PROCEEDINGS

OP THE

ROYAL SOCIETY OF MEDICINE

EDITED BY

Sir JOHN Y. W. MacALISTER

UNDER THE DIRECTION OF

THE EDITORIAL COMMITTEE

VOLUME THE SIXTEENTH

SESSION 1922-23

SECTION OF ODONTOLOGY

LONDON

LONGMANS, GREEN k CO., PATERNOSTER ROW

1923

Section of ©OontolOQs

OFFICERS FOR THE SESSION 1922-23.

President —

W. R. Ackland, M.R.C.S., L.D.S.E., M.D.S. Bristol.

Representative on the Council of the Society —

J. Howard Mummery, C.B.E., M.R.C.S., L.D.S.E., D.Sc.Penn.

Vice-Presiden ts —

(resident)

W. Warwick James, O.B.E., F.R.C.S., L.D.S.E.

E. B. Dowsett, D.S.O., L.R.C.P., M.R.C.S., L.D.S.E.
William Rushton, L.D.S.E.

(non-resident)

Henry R. F. Brooks, L.D.S.R.C.S.I.

J. B. Parfitt, L.R.C.P., M.R.C.S., L.D.S.E.

W. S. Holford, L.R.C.P., M.R.C.S., L.D.S.E.

Hon. Secretaries —

L. A. Harwood, L.R.C.P., M.R.C.S., L.D.S.E.

Harry Stobib, L.R.C.P., M.R.C.S., L.D.S.E.

J. Howard Mummery, C.B.E., M.R.C.S., L.D.S.E., D.Sc.Penn.

Hon. Curator— Sir Frank Colykr, K.B.E., F.R.C.S., L.D.S.E.

Other Members of Council —

(RESIDENT)

F. N. Doubleday, L.R.C.P., M.R.C.S., L.D.S.E.

G. Paton Pollitt, L.D.S.E., D.D.S.Penn.

P. J. Proud, L.D.S.E,

W. Kelsey Fry, M.O., L.R.C.P., M.ll.C.S., L.D.S.E.

F. J. Pearce, L.D.S.E., D.D.S.Penn.

R. Marshall Fickling, L.D.S.E.

S. F. Sfc.J. Steadman, L.R C.P., M.R.C.S , L.D.S.E.

E. C. Sprawson, M.C., L.H.C.P., M.R.C.S., L.D.S.E.

D. Reginald Curnock, L.R.C.P., M.R.C.S., L.D.S.E.

(non-resident)

H. O. Dickin, L.D.S.E.

Montague Philpots, L.D.S.E.

J. Clifford Wing, L.D.S.E.,

F. W. Broderick, M.R.C.S., L.R.C.P., L.D.S.E.

C. H. Housdkn, L.D.S.E.

G. A. Peake, M.K.dS., L.R.C.P., L.S.A., L.D.S.E.

A. T. Hilder, L.D.S.E.

F. B. Kirkman, L.D.S.E.

Arthur Rice, L.D.S.E.

Representative on Library Committee —

J. Lewis Payne, O.B.E., L.R.C.P., M.R.C.S., L.D.S.E.

Rcprcsentative on Editorial Committee —

F. N. Doubleday, L.R.C.P., M.R.C.S., L.D.S.E.

SECTION OF ODONTOLOGY

CONTENTS.

October 23, 1922.

W. R. Ackland, M.R.C.S., L.D.S.Eng., M.D.S.Brist.

President’s Address: Some Considerations for Preventive Dentistry

January 22, 1923.

DISCUSSION ON “DENTAL SEPSIS AS AN ^ETIOLOGICAL FACTOR
IN DISEASE OF OTHER ORGANS.”

Sir William Willcox, K.C.I.E., C.B., C.M.G., M.D., F.R.C.P. (p. 7), Sir Kenneth
Goadby (p. 17), Dr. William Hunter (p. 19).

February 26, 1923.

ADJOURNED DISCUSSION ON “ DENTAL SEPSIS AS AN ^ETIOLOGICAL
FACTOR IN DISEASE OF OTHER ORGANS.”

Mr. William Hern (p. 22), Dr. C. Kempster (p. 23), Mr. Colin Kbay (p. 24),
Mr. J. G. Turner (p. 24), Colonel McKechnik (p. 26), Mr. Charles Leonard
Gimblktt (p. 27), Dr. Graham Little (p. 27), Mr. W. R. Ackland (President)
ip. 28), Mr. A. T. Pitts (p. 29), Mr. Cribb (p. 30), Sir Frank Colybr (p. 81),
Sir William Willcox (in reply) (p. 32).

November 27, 1922.

DISCUSSION ON INFECTIONS OF THE TEETH AND GUMS IN THEIR
RELATIONSHIP TO THE NOSE, THROAT, AND EAR.

Dr. P. Watson-Williams (p. 85), Sir James Dundas-Grant (p. 39), Mr. Herbert
Tilley (p. 40), Mr. Mark Hovell (p. 40), Mr. A. T. Pitts (p. 41), Mr. W.
Stuart-Low (p. 41), Mr. E. D. D. Davis (p. 41), Dr. Watson-Williams (in
reply) (p. 42).

March 26, 1923.

Bernard Grkllibr (M.C.), L.R.C.P.Lond., M.R.C.S., L.D.S.Eng., D M.R.E.Camb.

Case of Multiple Dentigerous Cysts
J. Howard Mummery, C.B.E., F.R.C.S.

Case of Multiple Dentigerous Cysts

Contents

April 33, 1933.

Evelyn Sprawson (M.C.), L.R.C.P.Lond., M.R.C.S., L.D.S.Eng. page

On the Vascular Supply of the Enamel Organ of Felix domes t-ic-a ... 47

June 25, 1923 -

Professor Arthur Hopewell-Smith, M.R.C.S., Sc.D.

(1) Two Odontomes ... ... ... ... ... ... 55

(2) Some Observations on the Histology, Physiology and Pathology of

the Dental Pulp ... ... ... ... ... ... 58

April 23, 1923.

Gerald Harborow.

A Case of Unerupted Incisors and Canines in a Male, aged 59 ... ... 73

March 26, 1923.

May Mellanby.

The Effect of Diet on the Resistance of Teeth to Caries ... ... 74

The Society does not hold itself in any way responsible for the statements made or
the views put forward in the various papers.

John Bale, Sons & DanieUson, Ltd. 88-i‘l, Great Titelifield Street, London, W.l.

Section of ©Oontolo0\>.

President—Mr. W. R. Ackland, M.R.C.S., L.D.S.Eng., M.D.S.Brist.

Some Considerations for Preventive Dentistry :

PRESIDENT’S ADDRESS.

By W. R. Ackland, M.R.C.S., L.D.S.Eng., M.D.S.Brist.

I HAVE have been thinking a good deal about preventive dentistry: a
patient called my attention to a text in the Vulgate: Deuteronomy
xxxiv, 7

“Moyses centum et viginti annorum erat quando mortuus est; non caligavit
ocolusejus, nec dentes illius moti sunt.”

“Moses was 120 years old when he died ; his eye was not dimmed, nor
were his teeth loosened.” The latter fact interests us especially. Obviously,
from its being put on record, this was unusual. Indeed we may assume that
the loss or loosening of the teeth in old age was the rule even in those early
days. You remember that wonderfully poetical description of the advance of
age in Ecclesiastes, “ The grinders cease because they are few.”

Sir Thomas Horder in his admirable paper on “ Dental Sepsis,” read before
this Section in 1914, suggests that pyorrhoea is simply the pathological
hastening of the natural loss of teeth in old age. 1

I wish we knew more about the life of Moses and his habits, so that we
might have a chance of discovering why his teeth escaped even the “ pathology ”
of old age. Some further light might thus be thrown on the causation of
pyorrhoea. I think we may assume that he possessed a tremendous vitality.
His history shows him to have been a man of strong character. I remember
that our revised version says “nor his natural force abated,” instead of “his
teeth were not loosened.”

You understand that I mention this curious text in the Vulgate simply
because it started my thoughts about preventive dentistry, and as to how far
we had fallen away from such a standard as this (whether set by Moses or by
any of our prehistoric ancestors), or for that matter, from the standard in this
respect of many uncivilized races of to-day. I find no evidence that Moses
cleaned his teeth, yet presumably there was no caries. The same remark
applies to prehistoric skulls. There is no evidence of cleaning, and only
evidence of occasional caries or pyorrhoea. What a contrast with to-day—
* distinguished novelist says there are more dentists and fewer teeth !

Then I tried to imagine what 'fteve the habits, mode of life, and environ¬
ment of the possessors of these good teeth, in order to see how they differed
from those of to-day; and I came to the conclusion that the contrast in mode

l)-on j

1 Prort'aliih/s, 1911. vii (Sect. Odont.l, p. 6f».

[ October 2.J, 1922.

2 Ackland: Some Considerations for Preventive Dentistry

of life was just as great as the contrast in the condition of the teeth. I think
therefore that we may learn something as to the causes of our degeneracy.

To begin with, take (l) the question of their food . I suppose a good deal
of it was uncooked—fruit and vegetables certainly, and it was very fresh—so
I assume there was a full supply of vitamins.

(2) Their shelters or houses were very well ventilated and constantly
changed. They were mostly nomads, so that their habitat never grew stale.
Those of you who keep animals, especially poultry, know how important
this is.

(3) Their clothing was, to our modern notions, very inadequate, to say the
least—so that the sun and air had good access to their bodies.

(4) They used little or no artificial light, so I assume they had much more
sleep than we do. I lay great stress on sleep, first as a restorer of mind and
body, and secondly because of the recumbent position, and the consequent
removal of strain on the heart and circulation generally.

(5) Early marriage undoubtedly had its beneficial effect in two ways.
First, in the production of healthy children, and secondly, on the parents
themselves in promoting “the harmony of the hormones.”

(6) The children were never “pent up” in schoolrooms, nor were their
brains put under competitive pressure. So that the nervous system was free
to exercise its trophic influence on the proper development of their bodies.

(7) Finally, we must take into consideration the fact that the rigorous
conditions of life brought into uncompromising action the law of the survival
of the fittest— since there was little or no medical skill to keep alive the weak
and ailing. As a corollary, too, hereditation had the best material to work
upon.

What is the difference to-day ? Just the difference in all these details of
life, which civilization has brought about.

(1) Our food is cooked to the loss of vitamins, till the necessity for exer¬
cising our teeth is gone.

(2) Our houses are permanent habitations, very frequently with a long
history of previous tenants. Very often ill-ventilated, and generally grouped
together on stale soil. We change the living-ground of our animals (we say
it goes “ sour ” in Somerset) but we do not take the same precautions in our
own case.

(3) Our clothing it is difficult to criticize. We can scarcely get back to
woad ! though I remember how much better my horses were when they were
out at grass, than when they were “ rugged up ” in the stables!

(4) As to the importance and value of sleep I hold very strong opinion,
especially in regard to children. The children of the poor in cities do not
get sleep enough, one sees them about the streets at all hours. And even
in their houses, the noise and overcrowding can scarcely conduce to proper
rest.

(5) Of late marriage and resulting children I shall not say much, nor do
I propose to go into the subject of the “harmony of the hormones.” But I
shall hope to hear something, during my year of office, of the influence of the
ductless glands on the calcification of teeth.

(6) I have already hinted at the effects of the pressure of education
on the growing child. There is not the, slightest doubt in my mind that
the* pre-occupation of the nervous system in ill-nourished children is
mischievous.

(7) And I need scarcely remind you that the doctors’ skill to-day is pre-

Section of Odontology

venting the full operation of Nature’s law of the survival of the fittest. Hence
hereditation is perpetuating the ill-effects of civilization.

So far my remarks seem to be dealing with the effects of habits, mode of
life, and environment on general health, rather than on the teeth in particular.
Still, I am sure you realize from your knowledge of the causes of caries and
pyorrhoea, that my observations are not entirely irrelevant.

We learnt at the outset that so far from suffering from pyorrhoea, Moses
died with his teeth unloosened. The marginal reference in our Revised
Version, offers the alternative translation “ nor his moisture fled .”' So we
have the three versions: (a) “ his teeth were not loosened”; ( b) “nor his
natural force abated”; (c) “nor his moisture fled.” It is a picture of man
at his best, with his vascular system perfect. His terminal capillaries,
whether of eyes or dental periosteum, were in full working order. I am
inclined to attribute this to the excellent general health resulting from his
mode of life. For my clinical observation leads me to lay more stress on the
systemic than on the local causes of pyorrhoBa. It may be simply the question
of the amount of vital resistance, but it comes to the same thing. You will
see later that I am inclined to think that deficiency in vitamins plays its part
too in the production of pyorrhoea.

It is difficult to retrace our steps and undo the ill-effects of civilization
altogether. But can we do anything at all ? Well, preventive medicine is
doing its best, and I hope there is a chance for preventive dentistry.

The two evils we have to eradicate are caries and pyorrhoea , and the forces
fighting against us are: First, hereditation , which may predispose to caries
by a legacy of (a) poor-quality teeth, ( b) crowded jaws leading to irregularity,
(c) congenital diathesis such as syphilis, gout, rheumatism. Secondly, habits ,
mode of life , environment . Of these two, the latter group is obviously the most
important. It is the real evil, for without it hereditation would hand down no
legacy of trouble. And conversely, if we tackle successfully the evils of our
environment, heredity will not only right itself, but be on our side !

I have great hopes for the future based on an experience I had years ago.
A rich patient arranged for us to form a dental clinic on her model estate. We
were impressed at the start, by the fact that the teeth of the children, though
showing the usual neglect and want of cleaning, were fairly free from decay;
even though the teeth of the parents were in many cases bad. They lived under
the best conditions, their parents being a picked community of sober habits,
with good wages. So they had good homes, good regular food, good air and
plenty of sleep. Pickerill would say they probably walked to school munching
apples after their meals. I expect they did, as there were orchards all round
them. The best of milk was available, and plenty of eggs and fresh vegetables.

So far I have been giving you some impressions of my own—the ideas of
a mere clinician—gleanings based on the experience of every-day work, and not
derived from scientific investigation. Now let us turn to the scientists and see
what has been done to help us.

The experimental work of Pickerill was, I consider, the most serious
attempt up to ten years ago, in the direction of preventive dentistry. In
the introduction to his “ Prevention of Dental Caries ” (1912), he boldly
attacked the assumption that dental disease was inevitable, and then pro¬
ceeded to upset a good many of our established ideas as to care of the
teeth and as to dietaries.

Broderick 1 has been demonstrating the share which the ductless glands

1 Proceedings, 1921-22 (Sect. Odont.), p. 22.

4 Ackland: Some Considerations for Preventive Dentistry

take in the calcification of teeth, and that dental decay therefore is due to
endocrine insufficiency.

The investigation of ultimate causes has been carried more deeply by
Dr. and Mrs. Mellanby and others, in their experiments with the accessory
food factors or vitamins. Mrs. MellanbyV investigation of the influence of
diet on teeth formation, has led to some astonishing results. Her summary is
as follows:—

(1) A diet containing vitamin A will produce sound teeth in a puppy; (2)
conversely, a diet deficient in vitamin A produces the following effects: (a)
delayed loss of first set; (fc) delayed eruption of second set; (c) overcrowding
and irregularity from want of jaw development; (d) hypoplasia ; (e) low
calcium content; (3) this is an effect produced from within, and not the
result of oral secretions.

McCarrison in his experimental work on deficiency diseases, 3 shows that
deficiency in the accessory food factors leads to endocrine insufficiency.

Hence the work of Pickerill, Broderick and Mrs. Mellanby is all intimately
linked up. They have all tackled the problem of dental caries from a different
standpoint, but their united efforts have led us a long way on the road to
preventive dentistry.

The accessory food factors are a most fascinating study. The part that
the elusive vitamin plays in diet, is comparable to the effect of the spark on
petrol in a motor car. I had long felt that the association of the effect of the
accessory food factors with preventive dentistry was only a question of time,
and I had already been led to connect the trench mouth cases, of which we had
so many during the war, with a deficiency in vitamin C—the anti-scorbutic
vitamin. I regarded the presence of Vincent's bacillus as a secondary matter.
You will remember that vitamin C is destroyed by heat or drying, and is
absent in animal and vegetable oils and tinned meats, and practically so in all
cereals and pulses. Hence the rations were often deficient in vitamin C.

We had a dysentery ward or two during the war, and we found most of
the cases suffering from an acute or subacute form of periodontitis-one might
call it a form of pyorrhoea. McCarrison says that dysentery is practically a
deficiency disease, arguing from the fact that on the one hand a defective diet
is necessary as a favouring factor; and on the other that a vitamin diet is
necessary to produce a cure. Of course it is a fact that many individuals are
“carriers"—i.e., are infected without developing dysentery till the deficiency
in vitamins has prepared the way.

I therefore look upon pyorrhoea as a disease of deficiency•

What is the practical outcome of all these disjointed remarks ? What is
the plan of campaign in other words ?

We must start with the mothers , because the teeth begin to be laid down in
the second month, and to be calcified in the fifth month of pregnancy.

I am called upon to lecture occasionally at women’s institutes and clinics.
Our first care is to see that the mother has a diet rich in vitamins—butter,
whole milk, eggs, meat, and especially meat fats—liver, kidney. Of the fishes ,
herring and salmon are good (most white fish are useless in this respect).
Of the vegetables —cabbage, spinach, lettuce, tomatoes, bananas, nuts—most
vegetables in fact are good, and better raw than cooked.

Crude cod-liver oil is very rich in vitamins. It has been given for years

1 Lancet, 1918, ii, pp. 767-770.

- “ Studies in Deficiency Disease.” 1921.

Section of Odontobgy 5

by farmers in my neighbourhood to pregnant animals, to enable them to pro¬
duce healthy young.

The infant should be breast fed for nearly a year, and from a properly fed
mother the child will derive the only ideal food. No substitute can quite take
its place. In addition, as dental surgeons, we know that such children escape
certain jaw deformities, due to teats employed in artificial feeding.

The growing children should get whole milk, butter (not margarine), eggs,
fish, oils, meat, especially fats, and liver. No tinned meats should be eaten
by them. They should take wholemeal bread—but excess of the carbohydrates,
such as sugar, biscuits, Ac., should be avoided.

Pickerill condemns tea as a beverage, and also as a meal, on account of the
carbohydrates generally accompanying it. He recommends that fruit should
be eaten after every meal, and especially before going to bed, and that the
teeth should be brushed with an acid potassium tartrate mouth-wash.

None of the observers have referred to sleep and its beneficial effects, on
children especially. I am convinced that a sufficiency of sleep should rank
with good food and hygiene in importance, and that the want of it is one of
the factors in producing much of the ill health, and incidentally the bad teeth,
seen in our slums.

The housing problem , with which are bound up overcrowding, want of
ventilation and hygiene generally, is unfortunately being tackled very slowly,
especially in crowded cities, where it matters most. The changing of the site
of our dwellings would be a “ counsel of perfection ”—an impossible suggestion;
but the provision of garden cities, plenty of space in the houses and around
them, seem to be meeting the needs of the case.

I may be reminded that much of what I have been saying also savours of
“ counsels of perfection,” but after all, it is for us to point the way.

I began with a text, and on reflection, I find I have inflicted on you the
tedium of a sermon, both in matter and in length. But the text gave us
something to think about. And my final reflection is, if our labour in pre¬
ventive medicine and preventive dentistry meet with success, will our
occupation be gone?

Section of ©bontolOQ\>,

President—Mr. W. R. Ackland, M.R.C.S., L.D.S.Eng., M.D.S.Brist.

DISCUSSION ON “ DENTAL SEPSIS AS AN ^ETIO¬
LOGICAL FACTOR IN DISEASE OF OTHER
ORGANS.’’

Sir William Willcox, K.C.I.E., C.B., C.M.G., M.D., F.R.C.P.

The consideration of the rdle of dental sepsis in relation to disease of other
organs is one of the most important problems in medicine. It is certainly
true that infection of the teeth and gums, by reason of the streptococcal
infection arising from them, is one of the greatest sources of disease of adult
life.

The exact part played by dental sepsis in the causation of disease of
other organs demands in each individual case the most careful scientific
investigation, and the decision as to the best course to be adopted in the
interests of the patient calls for the exercise of great judgment.

The wholesale extraction of teeth without adequate supporting evidence is
to be strongly condemned, since it is generally injurious to the patient, and
does harm by bringing into disrepute, not only with the dental and the medical
professions but also with the public, an important factor in the causation of
disease. On the other hand the retention of harmful foci of sepsis in the
mouth in order to preserve teeth which are a source of infection is bound to
lead to impairment of health and disease of other organs. In every case of
dental sepsis one must consider not only the local conditions connected with
the teeth and the effects they have produced on other organs but also the
patient himself. There is no problem in medicine for which careful scientific
investigation and well balanced judgment are more required. It should not
be difficult to come to a decided opinion in every case of dental sepsis as
to what is the best course of procedure. It is most important that a true
perspective of the situation should be obtained, and in each case neither
too much nor too little done in the way of dental treatment and
extraction.

There is no department of medicine in which co-operation between the
dental surgeon and the medical practitioner is more essential.

Bacteriological Considerations .

The researches of Professor Miller, of Berlin, published in 1900, on the
bacteria found in dental infections, formed the foundation of our knowledge of
to-day. He found in twelve cases of pyorrhoea no less than twenty different
varieties of bacteria, amongst them streptococci, staphylococci, bacilli of various
kinds, and leptothrix.

In this discussion we are mainly concerned with the organisms occurring
in dental infections, the absorption of which or of their toxic products gives

My—Od 1 [January 22, 1923.

Willcox: Discussion on Dental Sepsis

rise to general disease. There is no doubt that it is the streptococcal infections
which are mainly responsible.

The streptococci found in dental infections are usually classified into
three groups, from their behaviour when grown on media containing blood,
viz.:—

(1) The H&molytic Group .—These decolorize blood-agar culture medium*
and lake-red blood corpuscles ; they cause severe toxaemia, and are found in
the anaemia resulting from dental sepsis.

(2) The Viridans Group .—These produce a greenish coloration when
grown on blood agar owing to the formation of methaemoglobin. Streptococcus
salivarius is the most important member of the group as regards dental
infections, and it is constantly found in the mouth. Streptococcus faecalis ,
another member, is occasionally found in dental infections- Both of these
organisms are toxic, and may produce general toxaemic symptoms, and even
malignant endocarditis. They are usually found in association with arthritis*
fibrositis and rheumatic affections. They produce less severe tissue reactions
than Streptococcus heemolyticus .

(3) The indifferent group of streptococci are not toxic to guinea-pigs, and
their association with rheumatic conditions is doubtful. Gram-negative cocci
are found associated with dental infections, but they are not usually toxic, and
some of these types have been described as staphylococci in earlier writings.
Staphylococci are not usually found in dental infections, but often in the post¬
nasal space.

In the infections of the teeth and gums the same streptococcus is not
necessarily found in different cases, nor can the local disease be constantly
transmitted from an infected patient by inoculation of the healthy gums of
another person, so that Koch's postulates of a specific infection are not
satisfied. The infecting organisms are variable, and the infection may be
mixed, so that the problem of dental sepsis is a complicated one.

The streptococci commonly associated with dental infections belong to the
viridans group. These usually produce only mild local tissue reactions and a
slight leucocytosis. They commonly cause general effects, such as disease of
other organs.

Staphylococcal infections contrast with those of the Streptococcus
viridans group in usually causing severe local tissue reactions such as boils,
carbuncles, and a high leucocytosis. They much less commonly cause disease
in other organs, but may occasionally do so, as for example in osteomyelitis and
malignant endocarditis.

Any of the organisms of the three streptococcal groups may be found in
the mouth of persons in normal health.

Dental sepsis forms a good illustration of the manner in which an organism
normally present in the body may cause disease when it gains access to the
tissues. Similar examples may be cited. Thus the pneumococcus found in
the saliva in health may cause pneumonia. The Staphylococcus aureus con¬
stantly found on the skin may cause boils or carbuncles. The Bacillus coli
comvmnis may cause cystitis or enteritis. It is probable that local tissue
damage and possibly an increased virulence of the streptococci found in the
mouth determine the occurrence of dental sepsis.

General Factors influencing the Effects of Dental Sepsis.

These are :—

(l) The Virulence of the Organism .—Just as in other pathological infections,
diphtheria for example, a small lesion may produce very severe effects if the

Section of Odontology

organism is virulent, while an extensive lesion with an organism of low
virulence may give rise to little constitutional disturbance. It is possible that
streptococci in passing from one person to another may gain increased
virulence, and also the entrance of streptococci into damaged tissues may lead
to an increase in virulence of the organism.

(2) The Amount of Toxic Absorption. —A most important factor. Everyone
who is familiar with hospital practice has been impressed by the appalling
dental sepsis observable to the naked eye in patients with no constitutional
symptoms arising from it. The reason must be that there is free discharge
of toxic products. On the other hand, an invisible deep-seated lesion with
healthy £ums may be associated with the most severe constitutional effects.

The ‘ time factor ” is important. If there is only slow absorption, the toxic
effects will be slighter than with rapid absorption. The whole question is one
of dosage with toxic products.

In a person in apparent health in whom slight dental sepsis is present the
toxic substances produced by the streptococci must be neutralized by the
body fluids, and the organisms must be ingested and destroyed by the leuco¬
cytes. It is the unneutralized toxic substance, and possibly also the organisms
themselves, which cause by absorption the effects of dental sepsis in the sick
person.

(3) The Resistance of the Patient. —A most important factor. The power
of neutralization of toxic products depends on the resistance of the patient and
his power of forming protective substances. As Mr. Stanley Colyer has put it,
the two important factors are “ the seed and the soil.”

Some patients, from constant absorption of toxic substance, become extremely
sensitized, and a condition of anaphylaxis results. The recent work of Sir
Almroth Wright on septicaemia is most interesting in this respect, since he has
shown that in certain cases of septicaemia the patient is incapable of developing
protective substances, and the leucocytes lose their property of ingesting and
destroying the virulent organisms.

Julius A. Toren, of Chicago, showed (1921) 1 that in certain cases of
dental infection and gingivitis a leucopaenia occurred, and he regarded this
as an anaphylactic phenomenon and a signal of danger. He concluded that
in this condition extraction of many teeth was dangerous, and advised
removal of not more than one at a time. The observation has a very important
practical bearing.

In severe cases of dental sepsis a vicious circle becomes established. Thus
the absorption of toxic products by its constitutional disturbance lowers the
resistance of the patient, and so leads to spread of the local infection and the
disease of other organs resulting from this infection. The importance of
general hygienic conditions which will improve the resistance of the patient
will be appreciated.

Family predisposition or diathesis plays an important part in dental sepsis.
Thus a resulting streptococcal toxaemia will produce in different persons
various respective manifestations, such as arthritis, gastric ulcer, anaemia,
gout, &c. It is difficult to understand exactly the determining conditions of
the particular disease occurring, but in many patients family predisposition
appears to be an important aetiological factor.

(4) Local injury may also be an important determining factor if dental
sepsis is present, as, for example, the occurrence of progressive arthritis of the

1 Dental Cosmos , 1921, lxiii, p. 492.

Willeox: Discussion on Dental Sepsis

hip-joint after an injury, or the development of infective streptococcal endo¬
carditis on the damaged valves of a rheumatic heart.

(5) Symbiosis is an important factor. Thus, the presence of another dis¬
ease such as scurvy or dysentery may lead to the rapid progression of dental
sepsis. On the other hand, the presence of dental sepsis is well known to have
an adverse effect in patients suffering from other diseases. Thus a septic
mouth adversely affects the prognosis in any acute disease such as typhoid
fever, pneumonia, &c. In cases of pulmonary tuberculosis it has been shown
by Dr. E. C. Wingfield that dental sepsis if untreated may frequently turn the
balance against the patient.

(6) Potential Health. —The consideration of this is very important. If
dental sepsis is present and no apparent harm is resulting, it does not follow
that the condition may be disregarded. In such cases danger is always
present. Thus in the condition of “ apparent health ” there is an equilibrium
between the protective power of the body and the toxic absorption. Should,
however, this balance be upset by the occurrence of some other disease, or
some depressing influence such as chill, injury, &c., then the presence of
11 dental sepsis ” is almost sure to assert itself and cause disease. In other
words a condition of potential health, not apparent health, is to be aimed at.

Evidence for the Conclusion that the Teeth and Gums are the
Source of Infection.

Dental sepsis causes a streptococcal toxaemia, and it is this which produces
its manifold disease effects.

A streptococcal toxaemia of exactly similar nature may result from many
causes other than dental sepsis; thus the tonsils, nasopharynx, intestine and
urogenital tract are common foci of infection in streptococcal toxaemia.

Because there is an association of certain diseases such as arthritis,
pernicious anaemia, &c., with dental sepsis it must not be assumed that in any
such case dental sepsis is the cause. For example, there is at present under
my care at St. Mary’s Hospital a patient (aged 58) suffering from pernicious
anaemia. His teeth and gums are, on clinical and radiographic examination,
found to be perfectly healthy. There is in this case a chronic antral and
nasopharyngeal infection of streptococcal origin which is the undoubted cause
of the illness. Careful examination must always be made to determine if any
foci of infection other than dental are present, and every case should be
approached with an open mind and no preformed opinion.

The Clinical Macroscopical Signs of Unhealthy Conditions of the

Teeth and Gums .

These when present will indicate dental sepsis. It must be borne in mind
that little or no evidence may be apparent from an external examination of the
teeth. Sir Frank Colyer rightly says in his book on “ Chronic General
Periodontitis ” : —

“ It is not safe to judge the extent of the disease from clinical appearances only,
and it is necessary to call in the aid of skiagraphy in order to ascertain how far
bone destruction has proceeded.”

The gums may appear healthy, and yet there may be an extensive disease
of the alveolar process around the roots of the teeth, and considerable bone
destruction, the involved area being heavily infected with pathogenic strepto¬
cocci. The grave clinical effects resulting from infected bone are well known,

Section of Odontology

and from observation of a large number of cases which have been carefully
investigated by bacteriological and radiological methods, I am strongly of
opinion that the general clinical effects producod by dental infections are
accounted for by the extent and nature of the disease of the bone in the
neighbourhood of the teeth, rather than by disease in the gums or the teeth
themselves, though these latter are the primary causes of the bone disease.

It cannot be insisted upon too strongly that in every case of illness in which
the teeth may be primarily responsible—even if external appearances of the
teeth and gums are healthy—a radiographic examination should be made to
ensure that the alveolar process around the teeth is also healthy.

Radiographic Evidence .

This will disclose the extent of the disease of the alveolar process. The
periodontal membrane of a tooth may be swollen, and the alveolus may show
superficial erosion, such as occurs with advanced age. Earefaction of the
alveolus round certain teeth may be present; but the most important evidence
of all consists in the presence of necrosis of bone in a more or less spherical
area around the apex of the tooth. These apical lesions are commonly called
"apical dental abscesses.” The term is a bad one, because there is no pus
present, and, most important of all, they give rise to no pain. The term “ apical
granulomata ” has been used ; this also is bad, because the microscopical
appearances are not those of a granuloma. When a tooth is extracted with an
apical dental lesion, a mass of solid gelatinous substance is found adherent to
the apex. This contains pathogenic streptococci and necrotic substance with
very few leucocytes. The term “ peri-apical bone necrosis ” would accurately
describe the condition actually present.

In my opinion, the “ peri-apical bone necroses,” the so-called “apical
dental abscesses,” are the most serious lesions found in connexion with dental
sepsis, and it is these which give rise to the gravest general disease resulting
from them. It is probable that from these lesions there is a constant flow into
the blood-stream of either virulent streptococci or their toxins, and the
anatomical position of the lesions prevents an adequate supply of leucocytes
and bactericidal body fluids to the part. If lesions of this kind are present
the maintenance of health is obviously impossible ; some serious general disease
is bound to result if it has not already appeared. If a lesion of this kind be
present no compromise is permissible; the affected tooth must be extracted.

An interesting point for discussion is the possibility of the dental radiograph
showing the existence of active disease, and whether the presence of a clearly
defined margin round the affected area of bone indicates protective resistance.

Secondary Infections .

Where dental sepsis is present the streptococcal infective process may
spread by direct transference of organisms to the tonsils, nasopharynx or
castro-intestinal tract.

Hurst has shown in cases of anaemia associated with achlorhydria that in
100 per cent, of cases streptococci are to be found in the duodenum, and in a
hrge proportion of these cases the streptococcal infection had a dental origin.

In cases of dental sepsis the colon almost always becomes infected with
streptococci sooner or later. Then, again, the organisms may be conveyed by
the blood-stream to other parts—as, for example, in malignant endocarditis of
dental origin. These secondary infections are usually progressive, and may
carry forward the same toxic process, causing disease in other organs.

Willcox: Discussion on Dental Sepsis

It can be readily understood why a disease of dental origin, for example
arthritis, may progress when the primary forms of infection or even all the
teeth have been removed. In many of such cases the intestine is acting as
the secondary toxic focus. It does not, therefore, follow that if dental sepsis
is removed, the disease which has resulted from it will necessarily clear up.
This consideration emphasizes the great importance of the early recognition
and removal of dental sepsis.

Dental Sepsis may be Secondary to some other Disease or Toxaemia.

An excellent illustration of this is scurvy, in which marked dental sepsis
is one of the earliest symptoms, and restoration of the patient to a dietary
rich in antiscorbutic vitamins will lead to rapid improvement and perhaps
disappearance of the dental sepsis.

The effect of mercury in causing dental sepsis is well known, and the
withdrawal of the drug may be followed by disappearance of the dental sepsis.

Bacterial diseases such as bacillary dysentery may be followed by dental
sepsis, which will abate and perhaps clear up when the primary condition is
cured.

In cases in which dental sepsis is secondary the removal of the primary
causal factor should be aimed at before an estimate can be formed of the
amount of dental sepsis present which will require treatment.

The General Diseases caused by Dental Sepsis.

Dental sepsis is a serious condition and may give rise to all the mani¬
festations of disease which are produced by a streptococcal infection. Thus
acute streptococcal septicaemia and sept i co-pyaemia have not infrequently arisen
from dental sepsis. The risk of this dangerous complication must always be
borne in mind in connexion with the extraction of infected teeth in patients
whose resistance to streptococcal infection is low. As already mentioned,
a leucopsenia is a danger signal.

Toxaemia is commonly associated with dental sepsis. It may be chronic,
subacute, or acute. Chronic toxaemia is present in a great many of these
cases, and in all cases where some general disease has resulted from the
primary dental infection. There is a feeling of malaise and general ill health,
a tendency to exhaustion on slight exertion, a pale and muddy complexion is
common, and often some general pains in the hands and feet indicate an
irritation of the peripheral nerves ; frequently some symptoms of fibrositis
or threatening arthritis occur. Insomnia, headache, and dyspeptic symptoms
are common. Sometimes severe wasting occurs, associated with general
weakness, the patient having an appearance similar to that in chronic phthisis.
Subacute toxaemia may give rise to intermittent pyrexia, with general
constitutional symptoms of ill health, extending over months and years.
In some cases pyrexia and general symptoms of ill health are followed by
profound acute toxcemia , and a condition of stupor, delirium, and coma results.

Local Infective Conditions resulting from Dental Infections.

Such conditions as stomatitis, tonsillitis, nasopharyngeal infections,
infections of the maxillary antra, cervical adenitis, and Ludwig’s angina
have been observed.

Blood Conditions.

A secondary anaemia, mild or severe in type, to which Dr. William Hunter
has given the name “ septic amemia,” is a common result of dental sepsis.
The more severe types of anaemia are associated with streptococci of the

Section of Odontology

haemolytic type. In many cases of pernicious anaemia a severe dental
infection with haemolytic streptococci is present, and is one of the most
important causal factors.

Leucocytosis is commonly present, and usually the differential count
approximates to the normal. It may show variations in different cases, and
in the same case at different stages of the disease.

Some acute cases show a marked relative lymphocytosis. This may
be a true lymphocytosis, or simply an apparent lymphocytosis, due to a
polymorphonuclear leucopsenia. In cases of lymphocytosis it is the large
mononuclear cells which are increased.

An increase of the eosinophilia is uncommon. Two cases, however, have
come to my notice.

Cardiovascular Complications .

Streptococcal infections of dental origin may cause phlebitis and venous
thrombosis, and also arterio-sclerosis, which is not necessarily associated with
an increase in the blood-pressure. The changes in the arterial wall may give
rise to narrowing of the lumen with symptoms of intermittent claudication, or
even arterio-thrombosis.

Cardiac Conditions .—Tachycardia of toxic origin is often to be observed,
and pericarditis, myocarditis, and myocardial degeneration may occur. Endo¬
carditis when present may be of the simple type, such as occurs in acute
rheumatism, but not infrequently dental sepsis gives rise to ulcerative
endocarditis. Five such cases have been under my care during the past
three years ; in these the origin of the infection appeared to be definitely
the teeth.

Blood-Pressure .

In some cases, especially those associated with gouty symptoms, dental
sepsis may cause a raised blood-pressure. In other cases of the asthenic type
the blood-pressure may be lowered below the normal. Attacks of angina
pectoris may occur in those cases with lowest blood-pressure just as in those
with raised blood-pressure.

Respiratory Complications .

The streptococcal infection may give rise to laryngitis, tracheitis, and
bronchitis. Pleurisy and empyema were described by Hunter in 1900 as
possible complications. Septic broncho-pneumonia is a serious and not
uncommon complication, and it may be followed by bronchiectasis, or lung
abscess.

At the present time a patient is under my care in St. Mary’s Hospital
suffering from abscess of the lung the result of very severe dental sepsis.
Attention has been called to the adverse influence of dental infections in cases
of pulmonary tuberculosis.

Asthma is not infrequently due to a streptococcal bronchial infection and
dental sepsis may be an important aetiological factor in some such cases.

Gastro-intestinal Complications .

Dental sepsis is one of the commonest causes of gastric and intestinal
dyspepsia. Hunter, in 1899, laid stress on the frequency of toxic or infective
gastritis, and he then expressed the opinion that dental sepsis was the probable
cause of some cases of that rare condition “ phlegmonous gastritis.”

Willcox: Discussion on Dental Sepsis

Gastric and duodenal ulcer probably result from septic infection, and the
trend of opinion at the present time is that dental sepsis is a most important
cause. In my experience it is rare to find a case of gastric or duodenal ulcer
in which an adequate explanation of the cause cannot be found in the condition
of the teeth and gums, and I should say that dental sepsis was much the most
important aetiological factor.

In some cases of dental sepsis hyperchlorhydria results, whilst in others,
especially those associated with pernicious anaemia, achlorhydria is present.

Appendicitis, in many instances, is due to streptococcal infection, and
several cases have recently been under my care in which the primary infection
appeared undoubtedly to arise from the teeth.

Enteritis, with symptoms exactly like those of paratyphoid fever, including
enlargement of the spleen and similar pyrexia, may undoubtedly result from
streptococcal dental infections. The differential diagnosis can only be made
by complete bacteriological investigations, and by the recognition of the dental
disease for which often radiological examination is necessary. Three cases of
this kind have been under my care.

Colitis, simple and ulcerative, is frequently due to a streptococcal infection,
and in many of these cases the primary focus is undoubtedly connected with
the teeth. Peri-apical dental necroses will often be found in intractable cases
of colitis. Dr. N. Mutch has called attention to the frequency (84 per cent.) of
pathogenic streptococci in the colon, in an analysis of 200 cases of arthritis.
In 52 per cent, of these cases he concluded that the primary focus was a
dental infection.

Renal Complications .

Nephritis has been described by many writers as sometimes resulting from
dental sepsis. Pyelitis may also occur.

Liver Complications .

Toxic conditions of the liver are well known to result from streptococcal
infections and frequently these are accompanied by jaundice ; also evidences of
hepatic disturbance are observed in cases of dental infection. There can be no
doubt that hepatic efficiency is often impaired as the result of the toxaemia
from dental sepsis. Catarrhal jaundice (so-called) may be caused by dental
sepsis setting up a hepatitis from streptococcal infection which leads to
obstruction of the smaller bile ducts.

Skin Complications.

Rashes of an erythematous, urticarial, papular, and eczematous type have
been observed. Purpuric rashes may occur, especially where the streptococci
are of the haemolytic type.

Lupus erythematosus has been recorded in association with dental sepsis,
the removal of which has resulted in marked improvement and in some cases
in cure of the skin condition.

Dr. Graham Little and Sir Frank Colyer have recently had under treat¬
ment a case of alopecia areata in which the condition appeared to be definitely
due to dental sepsis.

Eye Complications.

Conjunctivitis, iritis, irido-cyclitis, episcleritis, keratitis punctata,) retro¬
bulbar neuritis have all been described as resulting from dental infections.
Undoubtedly vascular lesions, such as thrombosis of the central artery or
vein of the retina, may be so caused. Of special interest is retinitis.

Section of Odontology

Dr. Batty Shaw 1 has recently called attention to the great importance of the
toxic factor in this condition and undoubtedly dental sepsis is not infrequently
the cause.

Nervous Diseases .

The toxaemia from dental infections may give rise to cerebral conditions
such as abnormal mental states, melancholia, &c., and it is possible that
inflammatory conditions, such as meningitis, may be so caused.

Diseases of the spinal cord, such as combined sclerosis with its associated
anaemia, disseminated sclerosis, &c., are often due to toxic causes, and dental
sepsis must be included amongst these.

Peripheral neuritis may occur from the streptococcal toxaemia of dental
origin, and the sensory symptoms, tingling in and numbness of the hands and
feet, are of common occurrence. Local neuritis, such as sciatica, brachial
neuritis, &c., is a common result of dental sepsis, but these are better included
under the fibrositis group, because the cause is rather a perineuritis than a
primary involvement of the nerve fibres.

Rheumatic Conditions.

In a paper published in the British Medical Journal (June 4,1921, p. 805), I
called attention to the great importance of infection of the teeth and gums in the
causation of rheumatic conditions such as fibrositis and infective arthritis,
commonly called “chronic rheumatism.” “Chronic rheumatism” appears
from the Ministry of Health Reports to be the commonest disabling disease at
the present day.

Fibrositis. —The streptococcal infections so arising may give rise to the
various forms of fibrositis—namely, panniculitis, inflammatory conditions of
fasche, and aponeuroses—such as occur in lumbago and myalgrc conditions ;
inflammations of tendons and ligaments, such as stiff neck, and tender heels due to
involvement of the plantar ligaments. Dupuytren's contractions of the palmar
fascia ; inflammations of tendon sheaths, arterio-synovitis ; bursitis ; Heberden’s
nodes ; finger pads; fibrous nodules in subcutaneous tissue; local perineuritis
and neuritis, as in sciatica and brachial neuritis. Fibrositis in some of its
forms is the commonest occurrence in cases of dental and gum infections.

Non-specific infective arthritis , which includes the forms known as rheuma¬
toid arthritis, arthritis deformans, osteo-arthritis, and chronic villous arthritis,
is generally due to a streptococcal infection. Dr. Beddard, in a discussion
on the “ Morbid Anatomy and Histology of Rheumatoid Arthritis,” held at the
Medical Society in October, 1918, 2 expressed the opinion that 90 per cent,
of these cases were due to infection arising from the teeth, and my personal
experience approximates to this view.

It is well known that in cases of non-specific infective arthritis numerous
bacteriological examinations have shown that no living organisms are to be
found in the joints. It is probable that the streptococcal toxins give rise to
the inflammatory conditions. The recent work of Dr. W. E. Gye and Dr. E. H.
Kettle has shown that marked proliferative changes can occur in organisms
such as the spleen, through the action of colloidal silica, without the presence
of living micro-organisms.

Acute rheumatism is not commonly caused by dental infections, but several

i I'lnr* t 'lings, 1923, xvi (Sects. Med. and Ophth.), Discussion on “The Significance of Vascular
a:.d ntln-r Changes in the Ketina in Arterio sclerosis and Penal Disease,” pp. 1-5.

- Trans. Med. Soc. t Loud ., 1919, xlii, p. 20.

16 -

Willcox: Discussion on Dental Sepsis

cases have been described. The organism found by Poynton and Paine in
numerous cases of acute rheumatism closely resembles the Streptococcus sali-
varius and Streptococcus faecalis found in dental infections.

Gout .

In some cases of gout dental sepsis is important, and should be removed,
as far as possible, in every gouty patient. Dr. Llewellyn has expressed the
opinion that gout is the result of a toxic idiopathy to certain toxic protein
substances. Undoubtedly, the streptococcal toxins of dental origin are in not
a few cases the important causative factor.

Diabetes.

Streptococcal and other toxins may cause a toxic glycosuria, probably by
impairment of the endocrine function of the pancreas. Dental sepsis is,
undoubtedly, a factor in the causation of glycosuria in some cases, and it
should always be removed in cases of diabetes. A rise in the carbohydrate
tolerance has often been observed by me after the removal of dental sepsis in
early cases of diabetes.

In cases of glycosuria a toxic factor should always be sought for, and
frequently dental sepsis is found to be the cause of the condition. In such
cases removal of the dental sepsis is essential and should form one of the first
elements of the treatment. In a number of cases under my care this procedure
has been followed by a disappearance of the glycosuria. It seems probable
that diabetes mellitus is caused in some cases by the irrecoverable damage to
the islets of Langerhans by the toxic absorption from dental sepsis.

Hyperthyroidism.

An excessive activity of the thyroid gland may undoubtedly result from a
streptococcal toxaemia. In one case under my care a tonsillar streptococcal
toxaemia gave rise to enlargement of the thyroid gland, rapid pulse and other
symptoms of hyperthyroidism: Enucleation of the septic tonsils was followed
by a complete disappearance of the symptoms. In an analysis of 100
consecutive cases of dental sepsis giving rise to disease in other organs, hyper¬
thyroidism was observed by myself in four cases.

Dental sepsis is usually regarded as one of the [etiological factors in
exophthalmic goitre.

Scurvy.

This disease, due to vitamin deficiency, usually shows marked dental sepsis
on its earliest appearance. During the war over 20,000 cases of scurvy occurred
amongst Indian troops in Mesopotamia, many of which I examined personally,
and in almost all very marked infection of the teeth and gums w T as present.
The result of careful observation showed that if pre-existing dental sepsis was
present in a marked degree, then such patients were very predisposed to
develop scurvy.

As an illustration of the respective frequency of occurrence of disease in
other organs in cases in W'hich dental sepsis was marked and appeared quite
definitely to be the important [etiological factor the following table is given. It
represents the last 100 consecutive cases I have seen (rheumatic cases are not
included).

Section of Odontology

-17

Table I.

Colitis

i Carbuncles

Toxjrmia (mild general)

. Appendicitis ...

Toxaemia, acute

Venous thrombosis and phlebitis

Septicaemia, acute

Enteritis

Glycosuria ...

Gastritis

Salpingitis
i Asthma

Gout...

Malignant endocarditis

Duodenal ulcer

Retrobulbar neuritis ...

Hyperthyroidism

Severe amemia

Nephritis

Melaena

Skin rashes ...

Arterio-sclerosis liaunorrhage ...

Cardiac irregularity (extra-

Combined sclerosis

systoles),..

Broncho-pneumonia ...

Boils

As illustrating the frequency with which dental sepsis appears as the cause
of the rheumatic affections “ fibrositis ” and “arthritis” the following table
represents the last 100 consecutive cases I have seen.

Table II.—100 Consecutive Cases of Arthritis and Fibrositis.

Source of Infection.

Types of Rheumatic Cases.

Dental sepsis

Arthritis

Intestine

Fibrositis

Tonsils

(Including 3of brachial neuritis,

Urethra (gonococcal) ...

3 of sciatica, 1 of tender heel)
Acute and subacute rheumatism

Treatment .

The treatment of infections of the teeth and gums, and the disease arising
from them, does not come within the scope of this discussion. The most
important general principles in the treatment of such infections have, however,
been indicated, namely :—

(1) Removal of the focus of infection, either by extraction -of teeth, or
suitable treatment.

(2) It must be remembered that intestinal infections very frequently result
from dental infection, and that these may require treatment by such methods
as Plombi&res colon irrigations, or an autogenous vaccine prepared from the
streptococci found in the teeth and intestine.

Prophylaxis.

The early recognition of dental sepsis and its appropriate treatment would
be one of the most important factors in greatly improving the health of the
nation.

Sir Kenneth Goadby

observed that, as Sir William Willcox had said, dental sepsis became really a
discussion of diseases which arose from streptococcal infection. He (Sir
Kenneth) showed long ago that the staphylococcus was not a common inhabi¬
tant of the human mouth, and that in only about 15 per cent, of cases was
Staphylococcus aureus found present. But with regard to streptococci, the
late Dr. Washbourn and himself, as long ago as 1896, 1 read a paper before the
Odontological Society showing that the streptococcus was present in all normal
mouths. He would now sound a note of warning in regard to the question of
streptococcal infections. It was well known, by analogy, that the colon-
bacillus lived in the colon and that it was responsible for many infections ;
and it was known that, in certain instances, the Streptococcus salicanus was
found in lesions. But he could not subscribe to the idea that the streptococcus

1 Trans . Odonto. Soc ., 18%, xxviii, pp. 251, 252.

Goadby: Discussion on Dental Sepsis

found in every mouth, and on every epithelial cell shed from the oral mucous
membrane, could be accused of causing the large number of diseases likely to
arise from infection of the jaws. Holman showed some time ago that if one
took a streptococcus of the haemolytic type and grew it in conjunction with a
streptococcus of non-haemolytic type, in a very little time the haemolytic
streptococcus had grown down, and was no longer to be found. The Strepto¬
coccus viridans , mentioned by Sir William Willcox, was a secondary type of
streptococcus of the haemolytic type. But he could not agree that the ordinary
streptococcus of the mouth was the viridans , or that the ordinary common
streptococcus obtained from average normal mouths belonged to the viridans
group. It was one of the third group, which he (Sir Kenneth Goadby) had
shown was not one of the common infecting streptococci. He had recently
published some ideas on this question of disease of the mouth, and in his
chapter on diagnosis of diseases of the mouth, he had scheduled the strepto¬
cocci he had met with in many of the cases.

With regard to the arthritis, he had been able to show that arthritis was
directly caused by mouth lesions, and that one could produce definite lesions
of a rheumatic nature by the injection into animals of streptococci obtained
from the jaws, not the streptococcus of the mouth, but one which had some
other existence, and which he called a strepto-bacillus at the time, because it
took on a bacillary form. It was one of the streptococcal group, of the viridans
type, and should be properly so called.

With regard to some of the other diseases to which Sir William Willcox
referred, he was glad to hear him sound a note of warning as to the extraction
of the teeth being considered the only method, or the method of cure. Of
course, the local infection must be removed, as in any other infective condition,
but when once the organisms had gained entrance, when the balance phase
was depressed in favour of the bacteria and against the resistance of the patient
to the organism, the removal of the cause was not, in itself, sufficient to take
away the disease itself, unless the particular body had great powers of
resistance.

He was interested to see the large incidence of colitis in relation to mouth
infection, and that the Strejrtococcus salivarius , i.e., the one found on ordinary
epithelial cells, was found. It was uncommon to find haemolytic streptococci
in the faeces examined. It had also been shown by several observers, especially
by Dible, that haemolytic streptococci disappeared quickly if injected into a
loop of normal intestine ; in seven or eight hours the haemolytic streptococcus
had been grown down by other organisms. He had made many searches for
haemolytic streptococci in the faeces of persons who had haemolytic strepto¬
cocci in their mouths, but in only 1 per cent, was it possible to demonstrate
those organisms in their faeces. In regard to cultures made from any normal
stomach much depended on what time of the day the culture was made. If
made the first thing in the morning, streptococci were always found in the
stomach. But if a culture were made later, or some hours after a meal, when
a good quantity of gastric juice had been secreted, haemolytic streptococci
were rarely found; certainly they were uncommon.

His experience of mouth infections was, that one found, in the very virulent
types, the streptococcus for which Holman suggested the name “ sub-
acidus”

There was another point which he was very glad had been brought out in
this paper, and it was one which ought to be recognized as a matter of general
importance. In the ordinary routine of practice one was met by the question

Section of Odontology

as to whether or not any given case might be said to be due to an infection.
It was sometimes very difficult to answer that question, and Sir William
Willcox had quoted Toren, Of Chicago. It was in 1920 that he (Sir Kenneth) 1
read a paper, in Boston, on the subject, and Toren had made use of some
observations he then scheduled of the association of leucopaenia and leucocy-
tosis, which he showed were common in oral infections. He (Sir Kenneth)
found that in the majority of dental infections, or of infections from the jaw,
leucocytosis was uncommon unless there was a direct infection of the blood¬
stream with the bodies of the organisms, but that the prodromal symptom
was polymorphonuclear leucopaenia ; and he took it that Sir William Willcox
was referring to septicaemia and toxaemia as if they were synonymous terms.
Toxaemia, however, by itself, was a different condition, from the pathological
point of view, from septicaemia. With Streptococcus salivarius no toxin
could be demonstrated, though it was possible it might have an endotoxin
which was pathogenic. He was inclined to the view that streptococci were
the organisms which gained entrance and caused damage by the presence of
streptococci in the blood-stream, and that had been demonstrated by a large
number of positive cases of streptococcaluria in these people; the streptococci
grown from the urine often showed the same cultural reactions and were of
the same type that were isolated from the patient’s jaws. Therefore he was
very pleased to find that the suggestion he had made of the importance of
blood examination was now adopted as a guide towards the right method of
treatment in cases of mouth infection. Finally, with regard to the cardiac
lesions referred to: in his experience, the average cardiac lesion met with in
chronic infections was myocarditis, rather of the auricular than of the ventri¬
cular type. The signs shown by polygraph or electro-cardiogram frequently
indicated damage in the upper, rather than in the lower portion of the heart.

The whole question of jaw infections, as the opener of the discussion said,
was one of streptococcal infection ; but it was necessary to be certain of the
type of streptococcal infection with which one was dealing, and it was impossible
to regard the ordinary streptococcus existing in everybody’s mouth as the cause
of arthritis, or of any other of the long category of diseases mentioned. He
demurred to the morphological classification of ail streptococci as one species,
and much more to the statement that the whole of the group caused disease.
The streptococcus could be obtained from anyone’s mouth, a vaccine prepared
from it and the patient treated, but this did not constitute a demonstration
that the streptococcus was a cause of the disease.

Dr. William Hunter

said i that Sir William Wilcox had given an admirable summary of the r6le of
sepsis in medical diseases. He (Dr. Hunter) looked back twenty-four years to
a meeting of the Odontological Society 1 at which he gave the first account of
his own work on the subject. That discussion was adjourned to the following
evening, and, as an American writer said, it had gone on ever since. Since that
date, the profession was divided into two camps : those who realized that
sepsis in the mouth was of great importance in medical diseases, and those
who considered that such importance was exaggerated. The issue really was
streptococcal infection, prevalent, potent and effective, as the greatest disease-
factor in medicine. It was immaterial to him as to what varieties of strep-

1 Joitrn . Nat. Dent. Assar., May-June, 1922.

- Trans. Odonto. Soc. t 1899, xxxi, p, 9*2.

Hunter: Discussion on Dental Sepsis

tococci were responsible for the infection, because twenty-five years of careful
observation had shown him that it was the streptococcus found in connexion
with the teeth that was chiefly responsible for the various septic infections met
with in medicine. The question of the varieties and reactions of streptococci
was most difficult, and that was shown by the long-continued and careful
work of Sir Kenneth Goadby and others, for there were twenty-six varieties of
streptococci known to bacteriologists. The important point was, that this
infection was present in the mouth ; and the matter of moment was, that it
was not the infection which was there in a free state, but in foci, in diseased
bone, and intensified in virulence by reason of this contact with diseased bone.
Twenty-five years ago he showed that the infection extended to the tonsils and
pharynx, from the pharynx to the stomach, causing septic gastritis ; to the
intestine, causing enteritis ; to the colon, causing septic colitis; the effects
extended to the blood, causing septic anaemia, which in turn produced effects
on the nervous system. He would like to deal briefly with two subjects :
(l) effects on the blood; (2) effects on the kidney and nerves. The effects
of oral sepsis were first brought forward by his work in connexion with
anaemia. It was not easy to know what had been the effect of oral sepsis
upon such conditions as functional nerve disease. The anaemia caused by
dental sepsis was not pernicious anaemia; it was a condition which he had
named “ septic anaemia.” The evidence of the part played by sepsis was
best shown in connexion with the blood. It was in such cases as when a
patient came in fainting and suffering from profound anaemia, and was found
to have only 23 per cent, of the normal quota of red cells. It was often
found in association with only a mild degree of dental sepsis. He found that
the sepsis extended to the antrum, the patient having muco-pus there. Three
or four teeth were removed, and the antrum washed out, and the result was
that in six weeks the patient went out with 73 per cent, of red corpuscles, as
against 23 per cent., and in nine weeks 91 per cent., feeling quite well. He
saw that patient recently—the treatment referred to having been carried out
ten years ago—and there had been no return of the anaemia. This effect on
the blood could be judged by actual percentages. In all cases of septic anaemia
there was a distinct leucopaenia, so that instead of the white cells being 100
per cent, of their normal number they were only 33, 55 or 60 per cent. On
removal of the septic focus, the percentage of white cells rose from 33 per
cent, to 81 per cent., the chief constituent change being in the polymorpho¬
nuclear leucocytes, which rose from 44 per cent, to 70 per cent. Perhaps
the best illustration of the action of sepsis was afforded by eye diseases,
patients having lost their sight as a result of iritis, choroiditis, or other con¬
ditions, as shown by Mr. Lang, in work dating from 1913, and by many other
observers.

His third group was that which he called the nephritis group. The rdle of
chronic septic absorption in causing kidney changes was described by him in
1903. It had during the last few years engaged the attention of many
clinicians—especially in America, with convincing results. Thus in the Mayo
Clinic, a study of sixty-four cases showed that forty-three had evidence of
tonsil infection, and forty-five had one or more abscessed teeth. Forty-five had
possible foci removed, with definite improvement in thirty-five cases, in striking
contrast to the results formerly obtained under ordinary measures of treatment.

A further point concerned the relationship of dental sepsis to mental disease
—actual insanity. When a man was a chronic dement and had to be con¬
fined in an asylum, there was definite evidence of trouble. Work in this

Section of Odontology

connexion had been carried out in the New York State Hospital for the Insane, by
Dr. Cotton, and it was one of the most important developments of the whole
subject of dental sepsis in medicine. Twenty-one years ago he (Dr. Hunter)
described cases of toxic neuritis, of paralysis of shoulder muscles and arms,
directly connected with oral sepsis, the ailments disappearing upon the removal
of the oral sepsis. Before that time there were no data of any such connexion. In
the ensuing twenty-five years he had seen oral sepsis responsible for all degrees
of neurasthenia. In 37,000 cases of insanity the presence of chronic infection
and the resulting toxaemia was a constant and most important factor. For all
groups of the insane, the conditions including dementia praecox, manic-
depressive insanity, general paralysis, senile dementia, alcoholic insanity and
other psychoses, the spontaneous recovery in ten years up to 1918 was 37
per cent.; since 1918 it had reached 77 per cent. For ten years up to 1918
the average mental discharges monthly in comparison with admissions was 43
per cent. In 1918 and since, the monthly discharges rose to 80 per cent. The
recognition of this factor shortened the period of residence in hospital.
Previously the average stay had been ten months ; during the last three years
it had been three months. He would give a concrete case of such a condition.
The kind of case was that of a person, aged 55, who had been two years in
hospital as a chronic dement, without having had any treatment directed to
her mouth. She was excited, talkative, depressed, agitated, and self-accusative.
Up to 1918 she remained in this state, but in September of that year she had
eleven teeth extracted. She improved rapidly, and four weeks later she was
discharged cured, and had since remained quite well. Case after case was
recorded among the insane on these lines, and the effect of the removal of the
septic foci was so great as to leave no doubt in the mind as to the causal
connexion. Twenty-one years ago, when dealing with the subject, he
emphasized what he still insisted upon, that the disease was so important that
it was not merely the province of the dental surgeon ; that the observation and
treatment of conditions in the mouth rested largely in the hands of the
physician, even though the problem as to howto treat those conditions devolved
upon the dental surgeon. In that connexion he exhibited two charts. The
first showed the immediate effect of removal of sepsis in a case of septic anaemia.
The blood count rose from 23 per cent, to 71 per cent., then to 80 per cent, in
six weeks. The next chart showed the effect of sepsis on pernicious anaemia
of a severe type, the life of the patient usually lasting one to three years.
The effect of the removal of the septic disease was an improvement from 20
per cent, to 30 per cent., and this amelioration increasing to 60 per cent., 80
per cent., and finally, 100 per cent, in the course of five or six weeks. His last
chart showed the effect of the removal of oral sepsis on the subsequent progress
of that grave disease pernicious anaemia, namely, that instead of ending life in
the first year or the second year, it now took the following course when the
sepsis had been dealt with: Great improvement, 60 per cent, to 80 per cent.,
which extended into the next year, with the possible continuance of the patient s
life to the fifth year. In two cases, as shown by the chart, the disease went on
for thirteen years and twenty years respectively. With those two classes of
facts in view, and taking into consideration the effect on the blood and the
nervous system of treating the sepsis, the causal connexion seemed to be quite
clear.

(The Meeting was adjourned to Monday, February 26 .)

Section of ©t>ontoloG\>.

President—Mr. W. R. Ackland, M.R.C.S., L.D.S.Eng., M.D.S.Brist.

ADJOURNED DISCUSSION ON “ DENTAL SEPSIS AS
AN ^ETIOLOGICAL FACTOR IN DISEASE OF
OTHER ORGANS.”

Mr. William Hern

said he quite agreed with the opening sentence of Sir William Willcox’s
address, in which he said that dental sepsis was one of the most important
problems in medicine. He (Mr. Hern) looked upon the mouth as the ante¬
chamber of the whole intestinal tract; as an incubating chamber for organisms
it was one of the most important cavities in the body. But Sir William was
largely preaching to the converted when he brought this subject forward. The
list of diseases the author gave was so formidable, that it seemed to confirm the
statement, “ We dig our graves with our teeth.”

But the term “ dental sepsis,” as used by Sir William Willcox, included
two quite different pathological conditions, with regard to both origin and
course. He referred first to the apical infections, due to the death of the pulps
and the decomposition of the organic contents in the root canals. The other
kind comprised the cases of growth of micro-organisms about the gum margin,
spreading into the surrounding alveolus, leading to pyorrhoea. Assuming that
Sir William Willcox was correct in his contention, that the streptococcal
group were the chief enemies in both these conditions, it was important to
assess the comparative potency for harm played by these as aetiological factors.
The worst part he considered was played by the gum infections, for the area
of toxic absorption was more extensive, the dose of toxic products was larger,
and the position of the focus of infection was more favourable for dissemination
of toxic products to the nasopharynx and to the gastro-intestinal tract by
swallowing. But he agreed as to the harm done by apical infections,
especially when the infection was deeply seated in bone, where leucocytes
were few, and phagocytes, because of their scarcity, not active.

He agreed as to the importance of radiographs of the teeth in all cases, to
determine the extent of the mischief and the correct treatment for the case.
If the plate taken showed a definite area of bone infection around the apex
of a dead root, extraction was the proper course. But he wished to emphasize
the importance of a true reading and deduction from the X-ray plate. There
was a tendency to regard all gum and alveolar absorptions as pathological,
but he did not think that was justified. There was a normal or histological,
as well as a pathological absorption. The alveolus was subject to variation ;
it was built up with the temporary teeth, and later with the permanent teeth,
and was swept away with them when they went. It was therefore a variable
quantity. But the absorption was pathological when associated with pyorrhoea
and other disease conditions of the gums.

[February 20, 1923.

Section of Odontology

There was also a tendency to regard all dark shadows in the negative as
pathological. One often saw a dark shadow near the apex of the lower pre¬
molars, but this was the mental foramen; there were dark shadows also seen
about the roots of upper molars, showing the dipping downwards of the floor
of the antrum. Further, the appearance of exostosis could be produced by a
curved root, i.e., when the plane of the photograph was oblique to the root
curve. Some slight rarefactions were also sometimes seen on the skiagram,
which he did not think meant disease. For instance in cases of straight-
rooted teeth which, after an attack of periostitis due to death of the nerve, had
been drilled into, and the pulp chambers and canals had been thoroughly
cleared and cleansed. He had watched such for years, and they continued
quite healthy, there had never been a gumboil or periodontitis or anything of
that kind.

With regard to the prevention of apical troubles in dead teeth, more care
was needed in thoroughly clearing pulp chambers. Short-cuts in treatment,
such as mummifying pastes, &c., where contents of pulp chambers were left,
should be abandoned. He was aware of the difficulty of being quite sure
that curved and inaccessible canals were quite clear of decomposing tissue; in
some cases such complete clearance was impossible. In a paper he read many
years ago before the Odontological Society the author laid stress on the import¬
ance of opening the canals in the long axis and of enlarging and reaming them
well out. This ensured thorough clearance and it gave a better chance of fol¬
lowing along a curved canal. With straight roots, however, it should not be
impossible to get the pulp canals quite clean.

The prophylaxis of gingivitis was a more simple matter; it consisted of the
inculcation of shampooing and frictionizing the gums with a fairly stiff tooth¬
brush, with or without an antiseptic; the latter being of only secondary
importance.

He agreed with Sir William Willcox that the earlier recognition and treat¬
ment of dental sepsis would be one of the most important factors in improving
the health of the nation. As already said, the list of diseases Sir William
Willcox gave as due to dental sepsis was somewhat appalling; he had stated
that 72 per cent, of the cases of arthritis were of dental origin, and he (Mr.
Hern) would like to know what percentage of these were apical troubles
of teeth, and in what proportion gingival or pyorrhceal troubles were the
cause.

Dr. C. Kempster

said that radiograms not only demonstrated the existence of a positive
condition, but also proved a negative condition. When the teeth and sur¬
rounding bony structures were not responsible for the condition of the patient,
that fact would be revealed by the skiagram. Hitherto it had been the common
practice to extract all the teeth, in the hope that some septic area would
thereby be opened up, and when neither the teeth nor alveolar processes were
at fault and this extraction had been done, the patient had suffered irreparable
loss. Where, however, teeth or alveoli were at fault, the skiagram showed it,
and defined the limits of disease, thus giving the dental surgeon precise
directions as to his treatment. He (Dr. Kempster) was frequently having
patients sent to him by dentists for radiographic examination because they
were supposed to be suffering from pyorrhoea alveolaris. He had found an
is-ue of pus between the teeth and gums, and often there was seen to be only
a peri-apical septic area, involving not more than two or three teeth ; in this

My—od 2 *

24 Kempster—Keay—Turner: Discussion on Dental Sepsis

way pyorrhoea was simulated. Wholesale extraction in such a case would
be obviously unfair to the patient. For many years he was radiologist to a
well-known orthopaedic hospital, in which there were many cases of arthritis,
some complicated with intestinal troubles. In all these cases he radiographed
the teeth-bearing area, and in most of the patients he found pyorrhoea absent.
The trouble was frequently due to peri-apical sepsis, the treatment of which
led to very satisfactory results, for in 70 per cent, of the cases the arthritis was
either cured or much relieved. Sir William Willcox had suggested that all
cases of peri-apical infection should be spoken of as cases of peri-apical
bone necrosis—a term he (Dr. Kempster) did not altogether like; in many
cases with peri-apical lesions there was no evidence of bone necrosis.
Neither did he agree with Sir William that septic absorption took place from
all peri-apical lesions. For instance, in the case of peri-apical cyst, the
dense line of demarcation often observed suggested that a barrier had been
erected against septic absorption, and that idea was borne out in practice.

Mr. Colin Keay

pointed out that a very small area of infection sometimes kept up systemic
mischief for a long time. Recently a patient came to him who had been treated
for gastric ulcer for a year on and off. A radiogram showed a small abscess
at the apex of a lateral tooth. He removed the tooth and curetted out the
abscess thoroughly. In a month, without anything further being done,
the patient was well. There had been no outward sign of the abscess.

Mr. J. G. Turner

said those who, like himself, had preached for twenty years and more the
importance of dental sepsis, would find, in Sir William Willcox’s paper, a
welcome confirmation of their views.

But there must necessarily be points of divergence, and some of these he
would touch upon. He thought peri-apical infection was not more than half
the danger. There was an equal danger from the more superficial infection,
which meant the presence of putrid food and germs among the teeth, before
any pocketing took place, and actual ulceration on the toothward side of the
gum flap. The danger was as great as that from peri-apical disease. The
following was the history of a case in point :—

A patient, aged 38, had been suffering, since her 21st year, from violent migraine,
on the average once a fortnight; in her worst attacks her temperature rose to 103° F.
She came to him at the end of very careful medical and surgical attention in hospital
for six weeks. When she came from hospital she was seen by a dentist, who told her
she had pyorrhoea, and must have her teeth out, but before agreeing the patient was
advised to see the speaker. He found she had foul pyorrhoea, but no peri-apical
lesions. He took out four teeth, molars, for drainage, excised two or three small gum
Haps, scaled and cleaned her teeth, and taught her how to clean the teeth herself.
She had been free from migraine ever since, and she said life was now worth living.

In practice he thought the more dangerous condition was the superficial
one, which was liable to be overlooked. The danger began in early life, in
childhood, and that was the second point on which he joined issue with Sir
William Willcox, for he saw no reference in the opening address to dental
sepsis in childhood. There were certain conditions in childhood, such as
myopia at school age, which he believed to be mainly due to dental sepsis.
Dental sepsis in childhood might sow the seed of diseases of later life.

Section of Odontology

He would also controvert Sir William Willcox on the streptococcal question.
Sir William, like others, found that the streptococcus was practically the only
offender. When Drew and he were first able to stain germs in the gums and
granulomatous masses from the apices and roots, it was a surprise to them that
they did not find the streptococcus in as many cases as they had expected,
though it could be found superficially. From the deeper parts a diphtheroid
bacillus was often obtained; and in at least two cases they had specimens of
the jaw and of the stomach from people who had died of septic poisoning.
Both in the bone and—in large quantities—in the stomach walls they found a
diphtheroid bacillus. There was a difficulty in being sure when making the
bacteriological examination that one was not merely examining a contamina¬
tion. It was very easy to infect at the moment of extraction; and after, if the
tooth were put into a test-tube or laid on a flat surface, fluid was readily
drawn from the crown to the root and to the granuloma. The more careful he
was the less likely was he to recover streptococcus in his bacteriological
examination.

Why should not this tissue be called granuloma ? Many of the cases were
actual granulomata, showing multiplication of the fixed tissue cells which could
form repair tissue, though the larger number of them showed an infiltration
with round cells, almost to the exclusion of other histological structures.

And there was a small point which, he thought, might sometimes cause
confusion. Sir William said dental sepsis might be secondary to some other
diseases, such as scurvy. But surely the sepsis was the external and original
part in the mouth, and it could not be secondary'' to any disease, except for the
fact that the patient could not clean his mouth during the continuance of that
disease. If there were no sepsis in the mouth, he would get no dental
symptoms even though he had scurvy. There seemed to be confusion between
what was sepsis and what was the result of sepsis.

Sir William also said it should not be difficult to give a decided opinion in
every case of dental sepsis. But in practice it was difficult, especially in such
instances as eye cases, in which one was sure there was a certain small amount
of infection going on, and yet one could not be sure that by sacrificing the
teeth good would result. The only thing to do was to take the plunge, and
fortunately the procedure of taking out the teeth, even those that seemed
sound, seemed justified. In one case, in which the patient had only one eye
left, he took out the last four (apparently harmless) teeth, and the man had
remained well ever since.

He (Mr. Turner) agreed that the results of dental sepsis covered about half
the diseases of civilization. He had a comprehensive formula for use when
lecturing to students: there was no disease—ranging from illness due to
defective drainage or following a broken leg, to acute mania—which might not
be influenced by dental sepsis, and the diseases directly due to it included
about 50 per cent, of the ills of civilization—beyond enumeration in the few
minutes left for discussion. Of course, there were classic, almost sacrosanct,
diseases, and one heard complaints (such as that from Lord Dawson) that
port and parentage were being ousted from pride of place in the production
of gout. But, if a gouty man's teeth were cleaned and, where necessary,
extracted, he could be permitted to go on drinking his port or his beer.

What was wanted was a new view of medicine and surgery, which should
take into account infection first. If treatment directed against “sepsis"
failed, a covering diagnosis might be necessary.

McKechnie: Discussion on Dental Sepsis

Colonel McKechnie

related the history of the following case, which was under his observation
while he was in India: —

The patient was an American dentist, who had been in India two years. Shortly
after arriving there he had an attack of fever, which was diagnosed as malaria.
After a year, he had another attack, which lasted a long time. Blood examinations
had been negative. When the third attack came on he (Col. McKechnie) was called
in. It looked like a case of typhoid ; the temperature was 103" F. on the second day
of the disease. When there was a suspicion of typhoid, he always took blood from
the arm at once, for if the diagnosis was delayed it was the worse for the patient.
In this case the blood slide was negative. But the pathologist incidentally remarked
that there was a contamination with staphylococcus. He (the speaker) had taken
many samples of blood without contamination, therefore he was suspicious, and he
asked the pathologist to make subcultures. Meantime, he searched the patient for any
septic focus. He was healthy and active, but pale. In twelve hours the report was
received from the pathologist that another germ had been found, streptococcus, and
his idea now was that it was not a contamination, but that the patient had septic-
semia. The patient’s temperature was still 103° F. He seemed to have a perfect set
of teeth, but one lower molar had been stopped ; he said it had never troubled him.
He (Colonel McKechnie) examined the tooth and percussed it. The patient admitted
that his fever did not come on until after the tooth had been stopped. As no other
cause for the condition could be found, he advised the extraction of that tooth, and it
was removed, and a medium was inoculated with it, and it was sent to a laboratory’.
The two organisms previously obtained from the blood were found—staphylococcus
and streptococcus. After that the patient rapidly recovered health.

Probably in some such cases the patients died without the conditions from
which they were suffering being diagnosed.

Sir William Willcox was very vague on the question of sepsis, and he said
that in one case a local efflorescence of a carbuncle resulted from sepsis. He
(Colonel McKechnie) believed that carbuncle often resulted from conveyance
of staphylococci by the blood-stream. The amount of toxin which would be
absorbed from the apical infection at one or two roots would be very small;
but if it was a question of absorption of the living germ, the case became more
serious. When Sir William talked of toxaemia, he often apparently meant
septicaemia. He (Colonel McKechnie) strongly advocated taking blood from
the arm for examination at the beginning, for if this were delayed till the third
or fourth day, the germs became more difficult to find, perhaps because the
antibodies had largely killed them off.

A further deduction from what he (Colonel McKechnie) had said was, that
every tooth in which a pulp cavity had been opened should be watched for
some months. When a pulp cavity had been stopped, it must be recognized
that the task did not end there. If the patient suffered from any ill-health,
the tooth should be skiagraphed, and if there were any indications of disease,
the tooth should be extracted. He imagined that the chief danger was apical
infection, causing septicaemia.

While in India his chief practice was in eye cases, and in every case which
came before him he examined the teeth. In India, among the class he saw,
practically every person over 30 years of age had pyorrhoea. Not that by any
means all beyond that ago were in bad health, but they would be ill if they
were suffering from bad apical infections.

Section of Odontology

Mr. Charles Leonard Gimblett

spoke of the bearing of dental sepsis on the work of the ophthalmic surgeon.
All admitted the importance of dental sepsis in regard to infection of the nose
and the nasal accessory sinuses ; and it was not a very far cry from the antrum,
ethmoid cells and frontal sinus to the orbit. The sphenoidal sinus was in close
relation, by way of its roof, with the optic chiasma, and an empyema of the
sphenoidal sinus had, in many cases, resulted in retrobulbar neuritis and
blindness. But there were three conditions, not so well recognized, which also
seemed to be intimately associated with dental sepsis. The first was irido¬
cyclitis—infection of the uveal tract—often very chronic, and difficult to be
sure about. There were but few symptoms: it gradually brought about
blockage of the spaces of Fontana, and increased the tension of the eye—
glaucoma—causing blindness. Dental sepsis was especially important when
this condition was uniocular ; one eye having glaucoma, the other eye being
normal. If these cases of uniocular glaucoma were examined, it was found
that there were floating vitreous opacities, and in some inflammation of the
uveal tract as evidenced by the condition known as keratitis punctata. In one
case of the kind he saw in hospital, the old lady had very foul teeth, and was
recommended to have them extracted. After this had been done the state of
her eye became much worse. It had to be recognized—and the patient should
be warned about it—that when the teeth were taken out the eye condition
might temporarily become worse. Another condition was macular degeneration,
which might occur for no apparent reason, in one eye, perhaps in both, but it
was difficult to prove actual connexion between this condition and dental
sepsis. The third condition in the same category w r as blepharitis and, to a
less extent, chronic conjunctivitis. The first of these conditions was often
very obstinate indeed, and in some instances the fact that the patient had
very septic teeth w ? as quite overlooked. He mentioned the case of a patient
with very bad teeth indeed, in whom the blepharitis was practically well
within six weeks of the cleaning up of his mouth. He promised attention to
the interesting point made by Mr. J. G. Turner about myopia at school age.
He saw T children of school age regularly several times a month, and some of
them w T ere unaccountably myopic, though their parents, sisters and brothers
were not. He w-ould now have them examined for dental sepsis. With regard
to the treatment of eye conditions by removal of teeth, one was, here, in the
same unfortunate position as those who had to treat osteo-arthritis : was one
justified in recommending that the patient should have his teeth extracted?
In some cases that measure produced no effect, but this should not deter
extraction, for although it was not certain that the teeth, at a late stage, were
the primary focus, there might be secondary foci, resulting from the dental
sepsis—foci w : hich were now lighting up the eye condition. An acute case
could he cured comparatively easily, but in many chronic cases it w r as difficult
under treatment to make any impression.

Dr. Graham Little

spoke of the importance of dental sepsis in relation to diseases of the skin ;
he said it was astonishing how frequently dental sepsis was found in cases
of skin disease of obscure causation. The history of one case under his
observation was quite sensational in this respect.

Little—Ackland: Discussion on Dental Sepsis

The patient was a lady who had very extensive sclerodermia, an atrophic disease
of the skin which caused large areas of the body to be immobile, and for which very
little could be done. She was under the treatment of Sir Thomas Barlow, who sent her
to Berne, to undergo an implantation of thyroid at the hands of Professor Kocher,
who had performed implantation in her case in two successive years. The amelioration
seemed sufficient to warrant a third visit, but Kocher refused a further operation, and
she returned with the condition practically unaltered. She was so crippled that she
could not feed herself, and had to be carried up and down stairs. Within a fortnight
of having her teeth extracted she was able to walk; she soon became able to feed
herself, and she was now able to type her own novels.

There were also some other diseases which, after persisting for a series of
years, reacted to removal of the teeth. One of the chief of these was that
formidable disease lupus erythematosus, which in rare instances had proved
fatal owing to practically universal septicaemia. Little could be done for the
condition. Cases of this disease were now improving remarkably after removal
of the teeth. A woman, aged 34, had an extensive, advancing lupus erythe¬
matosus, so rapid that he (Dr. Graham Little) had feared a fatal result.
A skiagram of her teeth showed them to be extensively diseased. They were
removed, a few at a time, and within three weeks of the first removals the
skin condition had notably cleared up.

Alopecia came into the same category in this connexion; he had a case in
which after the removal of diseased teeth there was a definite return of hair,
beginning within a fortnight of extraction of teeth.

There was also the large group of toxic eruptions, passing under the name
of erythema multiforme; these were often most satisfactorily treated by
examination and removal of teeth. It was unfortunate that all dentists were
not themselves alive to the importance of dental sepsis ; the speaker had had
several cases in which dentists refused to remove teeth which ultimately
proved to be diseased.

Alopecia of the beard he regarded as always due to dental sepsis. Lichen
planus was one of the most recent diseases to be associated with dental sepsis;
he was getting some cases which seemed to respond very specifically to
treatment of the teeth.

In regard to the number of diseases in which this connexion was being
established, it was difficult to know where to stop, but it was very evident that
dermatology was one of the latest specialities to recognize the fact.

Mr. W. R. Ackland (President)

said that the discussion did nob start off with a definition of the exact meaning
or oral sepsis or of its causes and sources. He assumed that any pathological
conditions of the mucous membrane of the mouth might, and did, contribute
towards it. There were three conditions pertaining more particularly to the
teeth : (l) Caries, in which there might not be exposure, but in which sepsis
might result as a product; (2) pyorrhoea alveolaris ; and (3) apical sepsis.
He wished to add to these, cases of ill-fitting dentures, for they led to a great
deal of illness. He had had three cases in which the patients suffered from
general malaise, with wasting, for a long time before the cause was discovered.
In one case the plate had ceased to fit, and the sides cut into the gum ; in two
others the trouble was due to the plate going too far back and the soft palate
moving against it.

Section of Odontology

These cases were so baffling, that he had laid down certain rules for
himself in examining them: (l) Dentists should not be over-impressed with
the importance of their own calling and expect that a case was entirely one
for dentistry. A case might be found to be due to a certain cause, and when
another case seemed like it one was apt to think the same cause was at work,
but often this was not so. (2) Occasionally cases were seen which were
attributable to two causes, and both had to be dealt with before the case
cleared up. (3) He believed that occasionally pyorrhoea was a result, not
a cause. There might be oral sepsis and general disease in a patient, both
having a common origin, for instance—pyorrhoea and iritis, the cause in
both being rheumatism.

Many years ago a boy who had been seeing an ophthalmologist came to him
(the President) and said he was very disappointed as he would not be able to get into
the Army, because his sight was defective. Incidentally, he had to put his teeth
right; the sight improved, he got into the Army, but was, unfortunately, killed in the
Great War. Apparently it was myopia due to oral sepsis. Recently he saw a case
which was sent to him by Dr. Burdon-Cooper, of Bath. The patient had a central
colour scotoma, and the skiagram he took showed apical trouble on the left canine.
This tooth was removed, and the patient lost his visual defect.

Recently again he had had a case in which there had been obstinate lacrymation
for two years, with inability to face the light or to read. The patient’s mouth was in
a terrible state. He found five apical abscesses, and removed all those teeth, then
the case cleared up almost at once. The punctum was not blocked, but the lacry-
mation and eye weakness were very definite.

The last case he would mention he had reported before, a lady with eyes of two
colours, one grey, the other brown. After some years’ acquaintance he had the
occasion to extract from her mouth a pivoted left upper lateral, and within three
months of that the brown eye had become grey. He inquired into her history, and
learnt that at 14 years of age, when at school, she had had intense trouble in that eye ;
immediately after, this tooth was crowned. Then came the change of colour of the
eye, and for fourteen years it had persisted, but it got right within three months of
taking out the lateral.

Mr. A. T. Pitts

said that from his student days he had adopted the views held by Mr. Turner,
and had always felt strongly that dental sepsis was of very great importance.
But his difficulties in any given case had increased as time went on, and he was
often perplexed to know what to do. In spite of all that had been said on the
subject, the problem appeared to him more obscure than ever. It was easy
to make the problem appear easy by assuming the various factors to be simple,
when they were not so. In nearly every case one had to depend on clinical
proof, for pathological proof was lacking. Thus the extraction of teeth,
because of some general condition assumed to be related to dental sepsis, was
an experiment which sometimes “came off,” but in many cases did not. When
a striking cure resulted it was supposed to be a case of cause and effect which
afforded an argument for similar treatment of like conditions. But if the
result was negative the significance was usually glossed over. He had been
much interested by a recent paper on achlorhydria in relation to other diseases
in the Lancet , by Dr. Hurst, 1 which suggested that there might be other factors

1 Lancet , 1923, i, p. 111.

30 Pitts—Cribb : Discussion on Dental Sepsis

which, conjoined with dental sepsis, made the latter a more serious event.
Dr. Hurst pointed out that achlorhydria was of frequent occurrence and in
some cases was of congenital origin. The stomach had an antiseptic as well as
a digestive function, the former being due to the presence of free hydrochloric acid.
Dr. Hurst thought that in most cases the swallowing of infected products from
pyorrhoea did not do much harm. But if achlorhydria was present the bacteria
passed undiminished into the intestine and set up excessive protein decomposi¬
tion which in turn might set up various infective conditions elsewhere.
Dr. Hurst suggested that this might account for some of the cases of osteo¬
arthritis which did not improve after the septic teeth had been removed.
In these cases a secondary infection in the intestine had been allowed to
become established, and achlorhydria was often present. He (Mr. Pitts) said
that Dr. Hurst went on to explain the association of achlorhydria and dental
sepsis in pernicious anaemia in a similar way, and had stated that it was of the
utmost importance to remove every particle of sepsis from the mouth in
pernicious anaemia, which usually meant the extraction of all teeth. In
striking contrast to this conclusion, Panton, Maitland-Jones and Eiddoch, in a
review of pernicious anaemia which appeared in a recent issue of the Lancet , l
said that they had failed to find any evidence of a causal relationship between
dental sepsis and pernicious anaemia. They strongly condemned the wholesale
extraction of teeth in this disease and remarked that they had known many
patients made miserable by the loss of all their teeth, some of whom had lived
long enough to contemplate, but not to use their dentures. What was the
dentist to do in face of this divergence of opinion ? He (Mr. Pitts) said that
Sir William Willcox seemed to assume that all dental lesions had a similar
infective value, but we knew little about the significance of apical infections.
The X-ray might show an area of rarefaction around a root but it might be
impossible to say what was the pathology of the condition. It might be a
granuloma, or an epithelial root tumour, or an abscess. It might even repre¬
sent a quiescent infection which had been walled off by the resistance of the
tissues. Clinically it might not be possible to differentiate between these
possibilities, yet, according to the author, all were equally to be condemned and
treated by extraction. This was a counsel of despair and suggested that dental
surgery was of little avail. Sir William had said that no crowned tooth should
be left in the mouth because apical rarefaction was so often seen in such teeth.
If this meant anything it meant that every tooth which had had the root canal
opened should be extracted, for it was this part of the operation and not the
fixing of the crown which might be followed by an apical infection. The r6le
of dental sepsis in general disease was undoubted, but much more pathological
work was needed to place the matter in its right perspective. It was
humiliating to reflect that our only means of testing the relationship in any
given case was to make an experiment and deprive the patient of his teeth,
which could not be replaced if the experiment failed.

Mr. Cbibb

reminded members that in the case of the teeth one was dealing with vessels
of very minute calibre, and any material resulting from bacterial activity
circulating in the blood would be felt there. It had been too lightly assumed
that the dental focus was the primary focus. In a number of cases in which
the teeth “ went wrong ” he was able to find that there had been such a

1 Lancet, 1923, i, p. 274.

Section of Odontology

condition as colitis at some previous time ; in such a way what was spoken of
as a vicious circle was established. From the presence of these products in the
pulp various effects ensued; he referred to decomposition, pressure, absorption
of bone. Necrosis of bone he did not think was so frequent as was often
t-hought. He did not agree with Sir William Willcox that in the case of these
teeth extraction was the only course; one could cut off the apex and get a sound,
workable tooth, the cavity could be curetted, and so the trouble be ameliorated
or cured. Pictures had been shown in one of the dental journals in
which regeneration of bone had occurred, and he did not think that
would have happened had there been necrosis. He agreed with Mr. Turner
that “ granuloma ” was a better name than necrosis. There seemed to
be a process analogous to that in dental cyst; a capsule was formed
which afforded protection. In extraction granulomata did not always
come away with the teeth. What should be done when they did not ?
Curettage should be done, as he did not think extraction would clear up
the trouble. The statement was freely made that such and such conditions
were dental in origin, but in the absence of proof such statements should be
accepted only with reservations. Scurvy had been mentioned. According
to the latest ideas, scurvy was due to the patient being deprived of certain
antiscorbutic vitamins, and from experiments made on animals fed on dried
hay, &c., it was clear there was a fairly immediate dental result; the tissues of
the pulp seemed to lose all character, and there was a mass of fibrous tissue,
with loss of any line of demarcation. Other experiments were made on guinea-
pigs in the way of depriving them of antiscorbutic vitamins, and if those
elements were absent from the food there was the same fibrous tissue formation.
Later the teeth became loose, particularly the upper molars. Glycosuria had
also been mentioned. When this occurred and sugar circulated in the blood,
the teeth would be affected by it first of all. People with diabetes often found
their teeth loosening. Much tooth trouble had its origin in the intestinal con¬
dition. Patients might seem to have healthy gums and teeth, but afterwards
one found marginal gingivitis, and they were found to have had colitis or other
intestinal trouble. Some years ago Mr. Turner had cited the case of people who
took too much whisky and who complained of their teeth feeling loose and
feeling uneasy. At present the large consumption of imported and prepared
foods, as to which not enough care was taken, was not a good thing. A
surgeon who had neuritis of severe degree in the arm had been sent to him. He
had marginal trouble in the gums, and there were pockets of pus. But he
only took one tooth out as it was somewhat loose; the others seemed to be
all right. After removal of the appendix the small amount of pus disappeared,
and he got well. Another patient contracted infective jaundice in Gallipoli and
was sent to Malta. His teeth became very loose, with pus welling up around
them. The R.A.M.C. surgeon suggested extraction of all teeth, but eventually
it was decided to keep the teeth if possible. The jaundice was cured, and nine
months later the teeth and gums were sound and healthy.

Sir Frank Colyer

remarked that the attention of the profession at the present time was so fixed
upon the question of apical infection that there was a little danger of their
losing sight of the far-reaching effects of septic absorption from the gum
margin. He pointed out that people might have septic mouths and yet show
no signs of ill-health ; nevertheless, in his opinion, the septic mouth must be

Colyer—Willcox : Discussion on Dental Sepsis

regarded as a source of potential danger. He drew attention to certain facts
about the physiology of the gingival trough and also to some investigations
which had been carried out on teeth removed from cases in which there had been
gingivitis; it had been found that the apices of these teeth were infected, as
well as the pulp cavities, and as far as the pulps were concerned, they all
showed a certain degree of fibrosis, which definitely pointed to the fact that
the infection of the pulp was of sufficient intensity to lead to certain tissue
changes. These facts would suggest that in all cases of septic conditions about
the gum margin active infection of the tissues around the teeth was taking
place, although for a time the defences in and about the teeth were sufficient
to prevent the infection passing into the general blood-stream; sooner or later,
however, these tissue defences broke down, with resultant damage in other
parts of the body. There was an important paper by H. Waller in the Lancet
(November 4, 1916), in which it was shown that in the case of mothers nursing
their infants—the children failing to gain in weight and even vomiting the
feeds—there was evidence that the trouble was attributable to the septic
condition of the mouth of the mother, for with the removal of the septic teeth
the children rapidly gained in weight. If the secretion of the mammary gland
could be so profoundly affected by dental sepsis, he (Sir Frank Colyer) saw no
reason why the internal glands should not also be influenced. He quite agreed
with Mr. Turner that one must not lose sight of the importance of dental sepsis
in children and expressed the view that a large amount of the infection from
which they suffered in later years originated in the early days of child¬
hood. Radiographs of septic teeth frequently showed very widespread infection
of the bone. If good results were to be obtained from the removal of the
dental sepsis, the dental sepsis should be removed when the tissues had a
chance of repairing—in other words, before the regressive stage of life. He
personally took out teeth much more freely for patients aged under 50 than
for patients over 70.

Sir William Willcox (in reply)

said he hoped he would not be regarded as an invader of the dentists* territory,
but rather as one who was accompanying them in exploring a region about which
neither he nor they understood everything, one over which the dental profession
held a mandate. In this matter there was need of cordial co-operation
between physician and dental surgeon, almost more than in any other subject.
The final decision as to extraction should rest with the dental surgeon.

He explained that he was regarding the subject entirely from the clinical
standpoint. He could give chapter and verse for all the conclusions he had
drawn. As Mr. Pitts said, judgment entirely from the clinical side might lead
to some errors, perhaps to some mistakes.

With regard to Sir Kenneth Goadby’s remarks, referring to the question of
leucopaenia in a paper read before the National Dental Association in 1920,
Sir Kenneth had given accounts of cases of dental sepsis in which leucopaenia
was present. This was at a date previous to the paper of Julius A. Toren of
Chicago mentioned in his (Sir William Willcox’s) opening address.

Dr. William Hunter’s contribution to the debate was most interesting, and
the profession was greatly indebted to him for his pioneer work.

Mr. William Hern asked what proportion of the cases of arthritis in the
series given in the paper were due to apical infection, and the reply was that
fifteen of the seventy-two were apical infections. Some of the cases, at the

Section of Odontology

time he saw them, had had all their teeth extracted, and he did not know what
was the condition of the teeth before they were taken out. He would say
apical infection was under fifty per cent. He agreed with Mr. Kempster that
peri-apical lesions revealed by the skiagram did not necessarily mean they were
the source of sepsis; such an appearance might be due to a cyst which was not
infective, or there might be an area of disease which was effectively shut off.
That, however, was the exception. He agreed also with Mr. Colin Keay that a
small lesion might cause a good deal of harm. He (the speaker) had a
skiagram of an apical abscess under a lower incisor tooth which Mr. Herbert
Smale had extracted; this was the undoubted cause of malignant endocarditis,
to which the patient succumbed. He confirmed Mr. Turner’s remarks as to
the importance of dental sepsis in childhood: he himself had had so little
experience of dental sepsis in childhood that he did not care to entrench upon
that subject. He agreed that streptococci were not the only organisms which
were the cause of the trouble, and, as Mr. Turner said, diphtheroid organisms
might play a part. The very interesting case mentioned by Colonel McKechnie
confirmed that view.

With regard to the question of scurvy, of people who suffered from scurvy
those who had dental sepsis in addition would have the worst degree of scurvy,
and dental sepsis was a predisposing factor if the diet was inadequate. It was
an instance of symbiosis, one disease leading to the development of another.

Mr. Gimblett and others emphasized the importance of dental sepsis in
various eye conditions; it was a sphere in which the significance of dental
sepsis was only now beginning to be realized.

He agreed with Colonel McKechnie that often what were called toxemias
were really septicaemias, as there was a constant incursion of living organisms
into the blood-stream. In what were known as toxaemias the organisms could
be destroyed; in septicaemias they remained in the blood much longer.

Dr. Graham Little’s contribution from the point of view of skin diseases
was very interesting. Perhaps when the causation of many skin diseases had
been narrowed down, the profession would not be so much bewildered with the
extraordinary long names in which that speciality abounded.

He also had been glad to hear the President's contribution, especially in
regard to ill-fitting dentures, and he agreed with him that all possible sources
of infection should be looked for, not only in the teeth, but in other organs.

Mr. Pitts gave a very critical review of the subject, and he could assure
him that he (Sir William) did not think he knew all about dental sepsis, and
he agreed that much more pathological work on the subject was needed. His
(the speaker’s) condemnation of crowned teeth was based on clinical experience.
A fortnight ago a patient who had been feeling ill with vertigo came to him.
He was about 50 years of age, and apparently had a sound mouth and
beautiful teeth. As he could not find any cause for the ill-health, he suggested
an X-ray examination of the teeth. Every one of the crowned teeth had an
apical abscess under it; and if Mr. Pitts would look at the series of
photographs exhibited, he was sure he would pardon him (Sir William Willcox)
for having taken a strong view on the matter. He frequently, as a physician,
found serious systemic lesions due to crowned teeth, and he was sure that at the
present day there was a large amount of careless crowning of teeth done,
causing much ill-health.

Sir Frank Colyer, who had done so much on the subject of dental sepsis,
asked why the removal of dental sepsis caused glycosuria to disappear, as it did
in many cases. The explanation appeared to be as follows: a patient who was

Willcox: Discussion on Dental Sepsis

continually receiving streptococcal poison into his system became sensitized to
the infection, and the islands of Langerhans became poisoned and paralysed, so
that they did not pour out the internal secretion, and glycosuria resulted. If
the teeth were removed in these early cases of glycosuria, the glycosuria did
disappear. And if septic teeth were removed in bad cases of diabetes, if the
glycosuria did not permanently disappear—which it did in some cases—
almost always the carbohydrate tolerance was considerably raised. He
believed the same applied to the causation of hyperthyroidism from dental
sepsis.

Sir Frank Colyer’s advice about removing infected teeth in people of
various ages was very wise. Sir Frank had told him that in elderly people,
sWith some retraction of gums and signs of gingivitis and dental sepsis, more
harm than good was done by wholesale extractions; with old people one
should go warily and gently. Sir Frank had dealt so forcibly with apicectomy,
that he (Sir William) had nothing further to add.

Section of <S>0ontolofl\>.

President—Mr. W. R. Ackland, M.R.C.S., L.D.S.Eng., M.D.S.Brist.

DISCUSSION ON INFECTIONS OF THE TEETH AND
GUMS IN THEIR RELATIONSHIP TO THE NOSE,
THROAT AND EAR.

Dr. P. Watson-Williams.

The discussion involves, on the one hand, our consideration of nose, throat
and ear conditions, resulting from infections of the teeth and gums, and con¬
versely, the influence of anatomical or pathological conditions of the ear, nose
and throat, in determining the incidence and course of infections of the teeth
and gums.

What constitutes clinical infection in one region does not necessarily apply
to other regions. The term infection is to be understood as implying an inva¬
sion of infective organisms with abnormal tissue reaction, for as in the colon,
so in the mucosa of the mouth and gums and the surface of the teeth and
pharynx, sepsis is normal, and even a degree of septic symbiosis is probably
normal and possibly beneficent. The degree of dental sepsis determining
abnormal invasion and commencing septicaemia varies within limits, but on
the other hand the nasal accessory sinuses are normally sterile.

Nasal and Aural Neuralgia of Dental Origin.

Neuralgia dentalis may be referred to the nose, suggesting antral , ethmoidal
or frontal sinusitis , x and particularly when a wisdom tooth is the source,
deep-seated earache may be the chief complaint. Dental pain referred to the
nasal sinuses usually originates in the upper teeth, through communications
of the dental nerves with the second division of the fifth nerves; while ear¬
ache is due to the communication of this second division of the fifth with
the tympanic plexus through Meckel’s ganglion, or of the third division of
the fifth nerve through its communication with the otic ganglion.

Periodontitis and Periapical Dental Infection.

Without entering into the debated causes and pathology of periodontitis,
I propose to use the terms— (a) Cervical infection to connote all the varieties
of septic infection commencing about the necks of the teeth ; (b) apical
infection to connote all processes arising primarily in or around the periapical
space, including granuloma, blind abscess or dental cyst formation.

1 Tboma, “Dental Disease in Relation to Diseases of the Nose ami Throat,*’ Boston Med. and
•W Joum 1918, clxxix, p. 17.

Jk—Od 1 [November 27, 1922.

36 Watson-Williams: Infections of the Teeth and Gums

Cervical Periodontitis (Pyorrhoea Alveolaris).

The incidence of cervical periodontitis, or pyorrhoea alveolaris, I believe
to be determined by two variable factors: (1) Lowered resistance from any
cause whatever, and (2) local trauma and infection. A high degree of oral
sepsis resulting from septic tonsils or infective nasal discharges may apparently
cause cervical dental sepsis, yet even under such conditions the incidence of
“ pyorrhoea” is largely due either to the lowered vitality of the patient or to
local trauma resulting from abnormal dental conditions.

Nasal obstruction resulting in buccal respiration appears to increase the
liability to cervical periodontitis 1 involving especially the anterior teeth rather
than the molars, and the importance of recognizing and treating the nasal
defects, septic tonsils and adenoids for success in overcoming dental sepsis is
emphasized by Colyer.

“ Cervical sepsis ” appears to affect the patient either (a) by direct toxic
absorption, or (b) by breeding pyogenic organisms which find their way into the
oral secretions, and, being swallowed, may cause gastro-intestinal infection, or
passing into the respiratory tract, cause infective laryngitis, bronchitis, &c.

The lymphoid aggregations in the fauces, namely, the tonsils, and those in
the pharyngeal mucous membrane, may become infected and septic, causing
acute or chronic tonsillitis or pharyngitis. Laryngologists realize the immense
importance of having septic teeth and gums treated before proceeding to operate
on the larynx, but it is well not to disregard dental sepsis before any opera¬
tion on the pharynx, and perhaps particularly the tonsils, since a sloughing
base after tonsillectomy (involving removal of the capsule) is fraught with
special dangers, e.g., purulent bronchitis, septic pneumonia, or septic pulmonary
infarct. In these conditions special care should be directed to the exclusion of
Vincent’s fusiform spirillum organisms, as they cause dirty and extensive
sloughing of wounds.

The wisdom teeth are frequently a cause of infective disease in the corre¬
sponding tonsillar region. The eruption of a third molar is often irregular
and difficult and liable to cause gingival traumatism ; infection (i.e., pyorrhoea)
follows and involves the tonsils. The infection may lead to an acute or chronic
tonsillitis and hyperplasia. More rarely peritonsillar abscess results ; of this
Canuyt records three examples. 2

Pyorrhoea sometimes gives rise to a spreading septic necrosis of the muco-
periosteum, tracking back from a molar to the fauces, and simulating peri¬
tonsillar abscess and sometimes involving the deep cervical tissues with pus
burrowing in the neck ; similarly angina Ludovici may arise from dental sepsis.
Unless we keep such possibilities in mind, the dental source of a tonsil¬
litis, peritonsillitis or septic cellulitis is liable to escape notice when these serious
complications arise, and constitute the dominant symptoms.

Peri-apical Dental Infection.

We must refrain from entering upon alluring problems opened up by a
general survey of apical sepsis in relation to infection of the dental pulp, which
is outside our discussion, but apical sepsis of the teeth in relation to the
maxillary antrum at any rate does concern the rhinologist, not only in the case
of adults, but also in that of young children.

1 Colyer, “Chronic General Periodontitis”; also Colyer, “Dental Surgery and Pathology.”

2 Canuyt, “ Les affections aniygdaliennes,” Archives Intermit, dc LarijngolOiol. rt
L'hinol., 19*22, xxxviii, j>. 9.%.

Section of Odontology

Apical granuloma may be secondary to maxillary antral infection , though I
understand that the prevalent teaching is that apical granuloma or abscess is
always secondary to septic pulpitis or pericementitis.

More than twenty years ago I expressed the view that “ some cases of
antral empyema are undoubtedly secondary to caries of the teeth, but there
is little reason to doubt that often chronic antral empyema is itself a
cause of caries of the teeth corresponding to the affected cavity.” 1 And the
cases recently published by Dr. Glassburg, 3 of New York, appear to afford
irrefutable proof of my contention that primary apical sepsis may be caused
by antral infection. In each of Glassburg’s three recorded cases, acute maxil¬
lary sinusitis occurred, and the teeth were reported sound by a dental surgeon ;
and, moreover, odontograms taken demonstrated the absence of any indica¬
tion of apical abnormality. Yet after an interval, varying from a few weeks to
a few months, during which, owing to the patient’s neglect, sinusitis was allowed
to persist untreated, when the teeth were again radiographed, primary apical
abscess had obviously developed.

What is the percentage of cases in which the teeth infect the antrum, or
nee versa, I do not venture to surmise, for at present reliable data are wanting.
Various authorities on diseases of the nose have committed themselves to
figures, and these vary so widely that no reliance can be placed on the
figures given.

Nasal Infection and the Dental Buds.

We have to realize that nasal sinusitis is by no means confined to adults,
for antral infection, as well as other forms of nasal accessory sinusitis, occurs
in young children or even in infants.

It would be interesting and useful to inquire whether acute purulent rhinitis
in infants is particularly prone to be followed by malformation and abnormal
dentition, for in early life the dental buds are in very close relationship with the
developing antrum, ethmoidal cells and lacrymal sac and duct. Schmiegelow
has recorded cases of acute osteomyelitis of the upper jaw in infants, with
swelling of the cheek and bard palate, falling out of dental buds, and alveolar
pyorrhoea. 3 Two similar cases are recorded by Vernieuve in infants of 5 weeks
and 2 months old respectively, though he considered the infection was derived
from the lacrymal sac in his two cases. 4

We have referred to acute or subacute maxillary antral sinusitis as a cause
of acute apical dental sepsis, yet it would seem to be quite as likely that chronic
antral infection should involve the teeth of the upper jaw in relation to the
antral floor—a chronic antral sinusitis is far more common than is generally
suspected, as it may exist without localizing symptoms or any notable purulent
discharge except for a short period after the acute exacerbations which are
generally regarded as severe colds in the head. Such cases are truly “ latent,”
the pyogenic organisms finding a suitable habitat in the mucosa, though
subject to inhibitory resistance of an otherwise healthy host.

But what of the dental apices, separated by a thin layer of bone and peri¬
osteum from the septic submucosa—and this thin bone capsule becoming more
or less decalcified, affording evidence of the pathological influence of the chronic
sepsis ?

‘ Watson-Williams, “ Disease of the Upper Respiratory Tract,’’ 1th eel., 1901.

* J. A. Ulassburg, “ Dental Infection Secondary to Acute Maxillary Sinusitis Jount. Anu-r.
Mni Amor., 1922, lxxviii, p. 883.

n Archin f. Laryngol. 1896, v, p. 125.

4 lire. (h■ Laryngol. September, 1921, cited Jonru. of Laryngol May, 19*22, p. 2ol.

38 Watson-Williams: Infections of the Teeth and Gums

We lack the data necessary for definite conclusions, and a rhinological
examination in a series of cases of apical sepsis of the teeth of the maxillae
would afford useful information. Recurring nasal catarrh, particularly if mainly
one-sided, post-nasal discharge, pain or tenderness over the antrum, nasal
polypus, subjective sense of bad smell or taste, all point to nasal sinusitis. But
in the chronic latent cases, special methods of examination may alone suffice
for the detection of a latent sinusitis of the antrum.

I must warn against too much reliance on transillumination; skiagrams
are far more trustworthy, but here again, a one-sided, thick-walled antrum
may mislead. The crucial test consists in sucking out the contents of
the antral cavity back into a sterile syringe, observing the presence of pus, and
submitting the specimen to the pathologist to determine whether there is
definite evidence of an active infective process, as evidenced by polynuclears
with phagocytosis, &c.

No dental surgeon to-day can fail to meet with radiographic evidence of
apical sepsis which otherwise must have remained unsuspected, inasmuch as
the involved tooth may seem sound and the apical sepsis without a local
symptom. These we may term “ latent; ” they are the analogue of latent
sinusitis. But the analogy between latent nasal sinusitis and latent dental
apical sepsis is far more important than a question of terms. The clinical
importance of these chronic quiescent infective foci, whether nasal or
dental, depends on the degree of toxin absorption and consequent systemic
blood poisoning; and inasmuch as the pathogenicity of the infecting
organisms varies from time to time, the patients’ symptoms are correspond¬
ingly inconstant. Often anaemic, the patient may exhibit a general lassitude
and a general neurasthenic syndrome, or possibly periodic neuritis, lumbago,
&c. More persistent manifestations may take the form of a canalicular
optic neuritis or rheumatoid arthritis, &c. We must not further enlarge upon
these systemic manifestations of sepsis in the nasal sinuses, in the periapical
spaces, or in any other part of the body. But rhinologists must pay
careful attention to the teeth whenever they find evidence of a latent nasal
sinusitis with these systemic symptoms, and conversely in cases with signs
of periapical sepsis the dental surgeon should not omit to investigate the
possibility of an associated or dominant nasal source of these symptoms.
In some of my own cases treatment directed to nasal sinus infection was
more or less disappointing because I had overlooked the co-existence of
apical dental sepsis, and in others where the patient had had all the teeth
removed little benefit followed because the chief source of infection lay in
the nasal sinuses. We want to collaborate in order to help patients more
effectively.

One point I desire to emphasize is that a “ latent,” slightly purulent, septic
focus may be a source of systemic symptoms as well as the more locally active,
purulent infections, for pus consists essentially of polymorphonuclear lympho¬
cytes which phagocyte or inhibit the infective organisms. We know that
a dissecting-room or post-mortem infection is less dangerous when it becomes
actively inflamed and rapidly breaks down from the very free invasion of
pus cells, whereas the non-suppurating infection spreading up the lymphatics
is much more dangerous and apt to end in acute general blood poisoning.
On the other hand, locally active suppurative processes may cause widespread
infective complications which may so overshadow the original and determining
source that, whether it be dental or nasal, the surgical measures essential for
the patient’s cure may easily elude our notice.

Section of Odontology

Is it not true that patients whose septic gingivitis is most purulent and whose
pockets of pus are numerous, often suffer less in general health than do a large
group in whom the pyorrhoea is “latent ” with no macroseopical evidence
of pus? In these quiescent cases the term pyorrhoea is really misleading;
there is little or no pus but inflammatory thickening of the periodontal
membrane associated with a progressive decalcification and absorption of the
alveolar bone and its coverings. The lesson is that local inactivity of a septic
focus is no criterion of its clinical import and danger. Hence for the dental
surgeon and for the rhinologist the general symptomatology is often the best
guide for active therapeutic measures.

Dental Cysts.

It seems to be generally accepted that dental cysts are formed (as a result
of stimulation by the chronic infection of a periapical granuloma) by
proliferation of the epithelial cells of Malassez, the mass forming a cavity
tilled with clear sterile fluid with a definite fibrous capsule. The cyst tends to
increase in size and invade the bone. Thus a dental cyst is a result of
periapical infection, almost invariably derived from septic pulpitis in a dead
tooth. Seeing that apical abscess can result from primary antral infection
involving a sound tooth, is it possible that chronic antral infection may also
cause the formation of a dental cyst? (We make no reference to follicular
odontomes as they are not due to infection of the teeth or gums, although they
may call for treatment on much the same lines as a dental cyst.)

The stereoscopic radiograms which are shown have been taken for me by
your President in cases of antral sinusitis. I think that some of these suggest
that sometimes the so-called spaces are in reality traversed by canaliculae
which are only partly absorbed (osteoid tissue) and are not constantly
indicative of true granuloma or abscess—in fact that they are due rather to
a progressive halisteresis and absorption of bone, similar to what occurs so
distinctly in the alveolar plates in pyorrhoea. To one of these I would invite
attention as it was taken for me sixteen years ago by the late Sir James
Mackenzie Davidson, and as an example of stereoscopic skiagraphy of the nasal
sinuses and teeth it would be hard to excel to-day.

Much yet remains to be learnt for the correct intrepretation of odonto¬
grams and in some cases the stereoscopic pictures are more helpful than
single prints. The absorption of alveolar plates and progressive halisteresis
may be but natural processes of senile degeneration, the analogue of bald heads.
Even abnormal appearances in the periapical region cannot, per se , be held
always to justify multiple extractions, in the absence of clinical symptoms or
other evidences of pathogenetic focal infection of dental origin.

Sir James Dtjndas-Grant

asked for more evidence of extension of disease from the antrum to the teeth.
He felt uncertain as to whether the presence of micro-organisms on aspiration
justified a diagnosis of antral inflammation in patients who, as Dr. Watson-
Williams stated, might still enjoy power of resistance to infection from them.
The speaker narrated a case of pain in the nose, seated in the anterior part of
the inferior turbinated body (supplied by the anterior dental nerve) accounted
lor by disease of an incisor tooth, cured by extraction of the tooth. In case of
antral suppuration in children he deprecated operation through the canine
fossa for fear of injuring the germs of permanent teeth in the superior maxilla.

40 Tilley—Hovell: Infections of the Teeth and Gums

Mr. Herbert Tilley

emphasized the importance of otologists teaching students that earache
associated with a normal tympanic membrane and good hearing was frequently
caused by a carious upper third molar tooth—in other words it was a
“ referred ” or “ reflex ” symptom. He quoted instances in which a combination
of labyrinthine deafness, tinnitus and vertigo (M6ni6re’s syndrome) had been
cured by the treatment of pyorrhoea. With regard to antral infection of dental
origin, he reminded members of the Section that in 1903 1 he had read a paper
before the Odontological Society in which this point was emphasized, and it was
suggested that diseased conditions of the teeth other than a septic pulp cavity
might induce antral suppuration. On that occasion the dental surgeons who were
present were almost unanimously of the opinion that infection of the sinus
could only take place when the pulp cavity was infected and the tooth “ dead/’
He gathered that present opinion was now in favour of the view which he
expressed nearly twenty years ago. He would be glad to have an authoritative
statement on the point from any of the dental surgeons present. His own
experience suggested that at least three-fourths of the cases of chronic antral
suppuration were due to intranasal infection. With regard to tonsillar
infection, he thought that the removal of diseased teeth was often followed
by a diminution in the size and in the septic condition of the tonsils. This was
particularly noticeable in young children. Dr. Watson-Williams’ views as to
the possibility of latent infections of the sinuses giving rise to symptoms were
well known to rhinologists and his observations and logical deductions could
not be summarily dismissed. All agreed that a purulent focus in a sinus
should be drained and cured, but were they all equally unanimous that the
non-purulent contents of a sinus, in the absence of other local pathological
conditions, might be of a high degree of infectivity ? If so, it would seem that
many apparently normal sinuses must be opened and drained by more or
less radical operations. This appeared to many to be rather an alarming
proposition. Bacteriology might help to settle the question because if it could
be proved that in normal conditions the secretions of the sinuses were
sterile, then the presence of pathogenic organisms would go far to establish
Dr. Watson-Williams’ views and the treatment based on them. He (Mr. Tilley)
was not aware that any extensive “ control ” experiments of this nature had
so far been carried out.

Mr. Mark Hovell

referred to the case mentioned by Mr. Tilley in which pyorrhoea was found
to be the cause of M6ni6re’s symptoms—but the explanation was simple :
M6ni6re’s symptoms were the result of the co-existence of gastro-intestinal
derangement, generally sepsis, and middle-ear catarrh, or an abnormal state
of the Eustachian tube. Pyorrhoea produced gastro-intestinal derangements
and these produced M6ni6re’s symptoms. He agreed with Dr. Watson-
Williams’ statement that transillumination was an uncertain test for antral
abscess. He (Mr. Hovell) had discovered this many years ago and was
surprised at the reliance still placed on this supposed test.

1 See Tram. Odont. Soc. (heat Britain , 19031, n.s. xxxvi, pp. 35-SO.

Section of Odontology

Mr. A. T. Pitts

said that he was very interested in hearing what Dr. Watson-Williams had
said about nasal sinusitis in infants. He had seen two cases, recently, of osteo¬
myelitis of the maxilla in infants. In both cases there were sinuses present
on the gum which led to the unerupted teeth. In one case he removed a molar
which was hypoplastic, and in the other a canine and molar which were both
deformed. It had seemed to him that the infection of the developing tooth
germs must be secondary to some infection elsewhere, but Mr. E. D. D. Davis
in conversation had informed him that some authorities considered that the
teeth were primarily infected. He was also interested in Dr. Watson-Williams’
statement, that in cases of periapical infection the sockets of the teeth should be
curetted and the outer alveolar bone removed. Surgical extraction, as it had
been called, had been extensively advocated and practised in America, though
in this country most dentists did not think it necessary. In the maxilla there
might be considerable risk of opening into the antrum. He should like to
have heard some more from Dr. Watson-Williams as to the treatment of dental
cysts in the maxilla. Many dentists (himself included) had thought that in
most cases the cyst encroached on the antrum and did not actually invade it.
The bony floor of the antrum became absorbed but the mucous lining remained
intact so that the antral cavity, although it might become greatly diminished,
remained shut off from the cyst. This had an important bearing on the
method of treatment. Assuming it to be true, unless there was clear evidence
that the antrum was involved or infected, the inner part of the cyst wall should
be left clear—no attempt should be made to dissect it out, lest, in so doing,
the antrum might be opened. He had followed this practice himself and had
found that if a large external opening was made the healing was rapid and
uneventful.

Mr. W. Stuart-Low

said that just as at the former combined meeting between the Sections of Ophthal¬
mology and Laryngology, held some years ago, 1 it was agreed that an operation
on the eye could not be safely undertaken until the rhinologist had freed the
sinuses of sepsis, so at this discussion it would doubtless be agreed that opera¬
tive treatment could not be safely undertaken on nasal sinuses until the teeth
and mouth had been freed from sepsis. He was also of opinion that chronic
antral sepsis was a result of neglected acute antral sepsis which almost always
arose during the course of influenza. The practitioner not having the advantage
of transillumination could not be expected to diagnose this trouble correctly,
the result being that this was often allowed to drift on to a chronic condition.
One proof that chronic antral sepsis resulted from derangement of anatomical
conditions in the nose was that disease of the antrum almost always happened
in a narrow nasal passage where a deviation of the septum existed, and while
disease of the teeth no doubt aggravated antral trouble it was rarely his
experience to find it the only cause.

Mr. E. D. D. Davis

said that Griinwald had stated that out of ninety-eight cases of antral sup¬
puration only fourteen were definitely due to dental infection. Out of 101 of
bis (Mr. Davis’s) own cases, twelve had been of dental origin.

1 “ Discussion ou Injuries ami Inflammatory Diseases affecting the Orbit and Accessory
Sinuses, - ’ Prorfjerfinf/s, 1919, xi (Sect. Ophtli. and Larvng.), pp. i-lxvii.

42 Davis—Watson-Williams: Infections of the Teeth and Qums

Antral suppuration of dental origin could be distinguished clinically from
that of nasal origin by the following points: (l) The presence of an alveolar
abscess or pyorrhoea of certain teeth ; (2) the antrum being the only cavity of
the nose involved; (3) the character of the pus, which was very foul, smelling
strongly of Bacillus coli and having a greyish sandy deposit, while antral
suppuration of nasal origin was more chronic and produced muco-pus of slight
or fusty odour; (4) the dental antrum being more easily cured by drainage
than that of nasal origin.

Dr. Watson-Williams had spoken of nasal antral infection producing an
apical abscess of the teeth. He (Mr. Davis) bad never seen it and he would
call attention to the fact that apical abscesses without caries occurred just as
commonly in the mandible as in the maxilla. Neither did he believe that a
dental cyst could arise from a nasal infection. A cyst of such an origin would
certainly not be a dental cyst. He agreed with Mr. Pitts that dental cysts
should be drained into the mouth, and opening into the nose and antrum
should be carefully avoided because the cyst lay well below the floor of the
nose, hence drainage into the nose was not good and a fistula between the
mouth and nose might result. The cyst encroached on but did not invade the
antrum.

The question of mouth-breathing and nasal obstruction was perhaps too big
a subject for present discussion, but he (Mr. Davis) had frequently seen patients
with as free and as patent a nose as a Cunard funnel, but yet they were
mouth-breathers, and dental surgeons had been more successful than the
laryngologists in treating the habit of mouth-breathing by the use of the
rubber mouth screen.

Dr. Watson-Williams

(in reply) pointed out that the question of the relative value of various clinical
tests in cases of sinusitis was outside the discussion, but as the question had
been raised, he would say that the reliability of the methods in use would have
to be decided by personal experience. Cystic degeneration of the nasal mucosa,
especially that arising in the nasal floor, might resemble dental cysts although
of very different origin.

Of course nasal sinusitis very frequently had nothing to do with the teeth
either in cause or effect; on the other hand, it was doubtless true that many,
if not most, diseases of the maxillary teeth were unassociated with nasal
sinusitis. Nevertheless, the purpose of the meeting had been to discuss
and consider cases and conditions in which there was such a connexion, in
order that some of the interesting problems arising in that way might be
cleared up.

In reply to Mr. Mark Hovell, Dr. Watson-Williams said that the vibrissae
of the nasal vestibule caught most of the inspired organisms and were therefore
always “ septic,” but in the nasal passages proper there were very few organisms
in health and none in the sinuses. They wanted more reliable guidance for
extraction of teeth that appeared sound, and the abnormal appearances at the
apical space revealed by odontograms required cautious interpretation. Radical
operative procedures for slightly septic tonsils, slight infections of the sinus and
doubtful apical and dental sepsis, were to be deprecated, but when clinical
symptoms could be definitely connected with such local infections operative
relief for their removal was indicated.

Section of <$>Donto!o0$.

President—Mr. W. R. Ackland, M.R.C.S., L.D.S.Eng., M.D.S.Brist

Case of Multiple Dentigerous Cysts.

By Bernard Grellier (M.C.), L.R.C.P.Lond., M.R.C.S.,
L.D.S.Eng., D.M.R.E.Camb.

Early in May last year I saw at the Royal Dental Hospital a boy, aged
13, with multiple cysts involving the maxilla and mandible. When I removed
them I sent them to Mr. Mummery, who had kindly consented to make a
pathological examination. Mr. Mummery and I are bringing this case to your
notice this evening. I propose before Mr. Mummery gives us an account of
the thorough investigation which he has made of these cysts, to preface
his account with a few brief remarks on the clinical aspect of the case.

The case was diagnosed as one of multiple dentigerous cysts. When the
boy first attended the hospital his face showed marked swelling on both sides
in the region of the malar prominences and a slight fullness on the right side
over the mandible. The history given was that a swelling on the left side of
the face was observed eighteen months previously ; it had increased since then.
Otherwise nothing had been noticed and no pain had been felt, till about a fort¬
night before he attended the hospital, when a throbbing pain was felt on the
right side of the maxilla, and this was followed in a day or two by a
discharge into the mouth. He was anaemic in appearance, and looked
somewhat delicate, but did not complain of ill-health.

His past history was that at birth there had been some inflammation of
the eyes; when 1 year old he suffered from meningitis, pneumonia, and an
inguinal hernia; when 3 years old he had had measles and whooping cough,
and when aged 11 he was attacked with broncho-pneumonia following
influenza. His tonsils and adenoids had been removed. With regard to
the teeth, eruption hfcd been delayed till he was nearly 2 years old.
There was no other dental history, and there was no family history
forthcoming.

On examination of his mouth it was found that the teeth present were the
permanent upper and lower incisors, all the deciduous canines, the first and
second deciduous molars, and the four permanent first molars. The tip of the
left second upper premolar was just showing on the outer side of the alveolus
above the second deciduous molar. All the deciduous molars were badly
diseased; in fact only the roots remained, except in two of them. The other
teeth were healthy.

In each region of the diseased deciduous molars there was a swelling. The
left upper swelling was the largest. It extended from the mid-line to the first
permanent molar on the outer side of the alveolus, passing high into the
buccal sulcus. Over its most prominent part it fluctuated, and it also yielded
the so-called egg-shell oraokling sensation. There was some corresponding

Ji— Od 1 [March 26, 1923.

44 Grellier—Mummery: Multiple Dentigerous Cysts

swelling in the palate, but it was not so extensive. There was no sign of
inflammation.

The right upper swelling was similar, but not so large. On its outer side
there was a sinus discharging pus. In the mandible on the left side there was
a slight bulging of the outer alveolar plate, and two hard nodular swellings on
the inner side, which were probably the two unerupted premolars forced
inwards by the cyst. On the right side of the mandible the swelling extended
from the deciduous canine to the first molar, and fluctuation could be felt on
the outer side.

In removing each cyst the portion of tissue holding the deciduous molars
was dissected away, attached to the cyst without disturbing the relation of the
deciduous teeth with the cysts. With regard to the unerupted premolars it
was not found possible, when dissecting out the cysts, to ascertain their
relation to the cysts. In the cysts of the mandible no tooth was found, and
the premolars could not be seen in the cavities left by removal of the cysts.
In the right upper cyst the second premolar was removed with the cyst, and
was lying loosely in it. It was well developed, except for the upper part of
the root, and in his examination Mr. Mummery found its relation with the
cyst. In the case of the left upper cyst both premolars were removed with the
cyst, but the second premolar had been driven inwards during the operation—
the tip of the crown was just showing through the gum. With regard to the
first premolar, I could not say what position it occupied in relation to
the cyst. The cyst on the right side was the only one which had suppurated.

The course of healing was uneventful. Deep cavities resulted from the
operations, but they are diminishing in size. About a month after the cyst on
the left side of the maxilla was removed the canine formed a swelling in the
anterior wall of the cavity and later erupted into it. In the mandible the
premolars were just erupting after about two months, and in the maxilla on
the right side the tip of the first premolar was showing in the cavity.

I hope to see the patient again soon, and I am anxious to learn how far the
cavities may be obliterated by new bone formation, and how the teeth will erupt.

(Radiographs were shown.)

Case of Multiple Dentigerous Cysts.

By J. Howard Mummery, C.B.E., F.B.C.S.

An interesting case of multiple suppurating dentigerous cysts was described
by Mr. Sprawson in a paper read before this Section in 1922, 1 and by a curious
coincidence this very similar case came under the care of Mr. Grellier, at the
Royal Dental Hospital very shortly afterwards. It is remarkable that cysts in
association with deciduous teeth had not been described and when Mr. Sprawson
wrote his paper there did not appear to have been any case recorded, but before
he read the paper he found and showed at the meeting a dental cyst containing
epithelium in connexion with the root of a deciduous molar. Sir Frank Colyer
recently sent me a cyst attached to a deciduous tooth in which I found a large
quantity of epithelium and a distinct epithelial lining to the cystic cavity, and
I prepared similar sections from the cysts on the deciduous teeth in Mr. Grellier’s
specimens, so that it would appear that cysts containing epithelium arising
from deciduous teeth are not so rare as had been supposed. It is probable that

1 Proceedings , 1922, xv (Sect. Odont.), p. 56.

Section of Odontology

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from their usually small size and the early absorption of the teeth they had
been overlooked. These were true dental cysts, in every respect conforming to
those found on the roots of permanent teeth.

The first cyst (fig. 1) removed by Mr. Grellier was a suppurating cyst—
it came away in a very complete condition and showed some very interesting
points. It was removed from the premolar region of the right maxilla and
showed a double sac attached to the deciduous molar. There was a slight
constriction at the junction of the sac attached to the deciduous molar with
the dentigerous cyst below it, but otherwise they appeared continuous. A
premolar came away at the same time ; it did not remain attached to the cyst,
but the tooth fitted accurately into the opening in the lower part of the cyst

Fig. 1.—Cyst No. 1.

Fio. 2.—Cyst No. 1.

Fig. 3.—Cyst No. 1.

(fig. 2). Without doubt the crown of the premolar had been within the cystic
cavity as the impressions of the two cusps, one longer than the other, were
plainly seen within it and the tooth fitted quite accurately into these
depressions. As in dentigerous cysts generally, the cyst wall only surrounded
the crown of the tooth, the incompleted root being altogether outside it. A
vertical section, and also microscopical sections of this case, showed the
line of separation between the dentigerous cyst and the granuloma on the
root of the deciduous molar, if it could be called a granuloma, for we can only
say that the dentigerous cyst was separated from the deciduous molar by
bone, connective tissue and numerous blood-vessels and a large quantity of
fat (fig. 3). In one part, however, there were a few clumps of epithelial cells

Mummery: Multiple Dentigerous Cysts

but very little granulation tissue. It is difficult to say if this is a true cyst
as it appears to be made up principally of connective tissue. It might,
perhaps, be looked upon as a cyst which has undergone further fibrous
degeneration. The dentigerous cyst showed an epithelial lining, but the
epithelium was not very abundant.

In the second case, the cyst, which was non-suppurating, could not be
removed in connexion with the dentigerous cyst, but this large cyst attached
to the lower right deciduous molar had all the characters of an ordinary dental
cyst. Sections showed enlargement of the epithelial rests, abundant epithelium
lining the cystic cavity and cholesterine crystals. The dentigerous cyst in this
case was removed separately but it can be joined up and appears to form a
complete closed sac, and as the cyst on the deciduous tooth was also closed
there cannot apparently have been any direct communication between the two.
Its connexion with the permanent premolar was not evident as the tooth did
not come away (fig. 4).

The third case was very interesting and the cyst was removed entire. It is

Fig. 4.—Cyst No. 2.

Fig. 5.—Cyst No. 3.

large and involves the roots of the deciduous canine and first and second molars
on the left side of the maxilla. As it appears important that the whole of this
specimen should be seen as much as possible in its original condition, I have
not made any microscopical examination of the portion beneath the deciduous
teeth although it may possibly be desirable to do this later. I have, therefore,
placed the deciduous teeth in position and filled the sac with cotton wool so
that the size and connexions of the growth may be clearly demonstrated (fig. 5).

There is a small cyst apparently connected with the root of the deciduous
molar and having no connexion with the large growth beneath it. Two pre¬
molars came away in this operation and the radiograph appears to show that
one of these teeth was within the sac, but it is impossible to be certain if it lies
within it or external to the cyst wall. The other premolar appears to have
been pressed aside by the growth and probably had no connexion with it.

The cyst in the fourth case could only be removed piecemeal and does not
give any definite information regarding the origin of the dentigerous cyst, but
there is a cyst in connexion with the deciduous molar.

Section of Odontology

All these cases appear to point to the fact that the dental cysts on the
deciduous teeth have no direct connexion with the dentigerous cysts. The
question arises whether in these cases the irritant which gave rise to the dental
cyst has not at the same time been the cause of the proliferation of the epithelial
rests surrounding the forming permanent tooth, and whether the two cysts have
been formed independently yet are due to the same cause. It seems difficult
to understand the symmetrical formation of these growths in both maxilla and
mandible.

Mr. Evelyn Sprawson said the authors had recorded a very interesting case. Mr*
Mummery had remarked on the symmetry of the cysts in his case; whether coincidence
or not the cysts in the case he had himself recorded last year were also symmetrical,
but here they were all in the mandible. He noted with great interest that in Mr.
Mummery’s case a deciduous tooth was still in situ over each cyst and that in each
case it was dead and infected, this being a point upon which he had laid some stress in
describing what he believed to be the pathology of such cysts. Since he had read his
own paper he had had occasion to cut sections of some six or seven granulomata on
deciduous teeth, and in each case he had found masses of epithelial cells present in
them. He thought that they differed in this respect from granulomata on permanent
teeth where epithelium was by nohneans always to be seen. Mr. Mummery had some¬
what stressed the point that he thought the cells giving origin to these cysts were always
those in the coronal portion of the permanent tooth follicle. This he (Mr. Sprawson)
had himself mentioned as being a possible source, but did not conceive it possible^*) say
that it was the only source, seeing that epithelial cells from the three possible origins
which he had given were so condensed into a small area—frequently in life measuring
0‘5 mm. or less in diameter—that the source of origin was necessarily lost, particularly
as this area moved with the growth and eruption of the tooth. Mr. Mummery had also
referred to the cysts having the histological characteristics of dental cysts ; he (Mr.
Sprawson) himself held that, histologically, both dental and dentigerous cysts were
identical except that in dental cysts squamous epithelium occurred with greater frequency
as a lining. Lastly, he thought it quite conceivable that multiple cysts might originate
on a tooth with many roots such as a deciduous molar, and that by the process of
absorption of the molar roots the cysts might become separated from the deciduous tooth
from which they originated. Since he had read his paper he had collected some six
cases in which the overlying deciduous tooth was still in situ , and in each of these it
was dead and infected, and so far confirmed his statements.

On the Vascular Supply of the Enamel Organ of Felis domestica.

By Evelyn Sprawson (M.C.), L.R.C.P.Lond., M.R.C.S,,

L.D.S.Eng.

The slides shown are photographs of transverse vertical sections of the
developing mandibular second premolar of Felis domestica . The sections from
which they were taken, which are also exhibited, show, in addition, the pre¬
ceding deciduous tooth in situ . They were prepared by decalcification and
freezing, staining with Ehrlich’s acid haematoxylin and mounted in Farrant’s
medium, any shrinkage due to dehydration and other non-aqueous reagents
being thereby avoided. The developing premolar has a large part of the
dentine of the crown formed, also a portion of that which goes to form the
root. An appreciable thickness of enamel has also been laid down, but nob

[April 28, 1923.

Sprawson: Enamel Organ of Felis domestica

fully calcified, in that the matrix of the portion so laid down still remains
after decalcification ; though at the coronal portion this matrix has been broken
away in the manipulation of the sections.

Fig. 1 is a photograph, at a magnification of 109 diameters, of the coronal
portion of the first section shown. The tissues seen, from above downwards,
are, I take it, as follows: Uppermost there is a layer of alveolar bone forming
the roof of the crypt of the developing tooth ; bordering on its inferior aspect
there is seen an irregular layer of large multinucleated cells, each cell of which
fits into a roughly crescentic excavation in the bone ; from their position, the
stage of growth of the specimen, and the type of cell, they are evidently
osteoclast cells engaged in absorption of the roof of the crypt preparatory to
the commencing process of eruption of the underlying forming tooth.

Fig. 1.—Coronal aspect of enamel organ and adjoining tissues, (x 109.)

Below tliis is a layer of connective tissue, moderately rich in cells, the
deeper portion of which I think represents the tooth follicle and, blending with
the superficial portions of the next layer, it can be traced laterally into direct
continuity with the tooth follicle. I say “ represents,” because in different
specimens, during its development, and particularly at its coronal portion, the
follicle presents a very variable thickness, and an appearance which may be
quite different from that of the adult follicle as usually cut and described; the
thickness largely depending on the proximity and amount of hard tissue, bone
. or tooth, which lies in the immediate path of the • advancing tooth,
and whether active absorption is going on or not. I shall refer to this again
shortly.

This tissue is occupied by numerous capillary blood-vessels, which are

Section of Odontology

seen in its middle and more particularly its deep portions, several vessels in
this latter position lying in immediate contact with the next layer, the external
epithelial layer, but none are seen to penetrate it. Most of these vessels are
cut transversely, and here form a very definite plexus immediately external to
this, the coronal portion of the enamel organ. Vascularity at this point is a
well recognized feature.

We now come to the enamel organ, which has, at this stage of its greatest
activity, already undergone certain changes from its original definitely outlined

Fig. 2.—Same as fig. 1, but x 455.

structure, in that the external epithelial layer no longer exists as a definite layer
of polygonal cells, but rather as a layer of flattened cells, very similar to those
cells of the sheath of Hertwig found at the point where a fully developed tooth
follicle joins the neck of the tooth. They are not unlike fibroblasts and, except
by analogy and comparison with the layers on either side of it, not easily
recognizable as being epithelial cells. They merge into the adjacent and
external connective tissue (follicle) layer on one aspect, and into the stellate
cells on the other, but in spite of this still maintain themselves as a very definite
layer, typical of the form assumed by this layer when condensed by the growth

Sprawson: Enamel Organ of Felts domestica

of the crown of the forming tooth. Deep to the external epithelial layer there
is a layer of cells, some nine or ten cells deep at the coronal portion, but
dwindling away on either side, and there becoming flattened, consisting of
the typical normal cells of the stellate reticulum, as shown when they are pre¬
pared by any histological method which eliminates shrinkage during the
preparation and mounting of the section. Apparently there are no blood-vessels
among these cells, but they are present on its deep aspect. The typical structure
of these cells shows a good deal better under the higher magnification of 455
diameters, as seen in the next two slides (figs. 2 and 3). The stratum inter-

Fig. 3.—Same as fig. 1, but x 455.

medium lies deep to these stellate cells, and consists of the typical cells of
this layer, though the layer seems denser than one usually sees it, possibly
owing to some obliquity in cutting. Beneath these is a normal ameloblast
layer, some of the cells of which are cut slightly obliquely.

A great many capillary blood-vessels, mostly cut obliquely or longitudinally,
and containing blood corpuscles, are seen lying on the superficial aspect of
these coronal cells of the stratum intermedium. Several of these blood-vessels
apparently penetrate the stratum intermedium layer of cells and meander

Section of Odontology

among them as far as midway in the thickness of this layer, but in some parts
of this section and in others these capillary vessels may be seen nearly, if not
quite, in contact with the ameloblast cells. Apparently this is a capillary
plexus within the enamel organ occurring at the coronal portion of the tooth.
I do not know the exact age of the animal from which the sections were cut,
but from data since furnished me I gather that it must have been about 3£ to

months old—the eruption of its permanent mandibular incisors was just
commencing.

It has been suggested to me that the layers which I have taken to be the
stellate reticulum and the flattened remains of the external epithelium are the
tooth follicle, and that if they be traced out laterally they will be found to be in
direct continuity with it; I do not think this is so, and the next slide (fig. 4)
taken at a magnification of about 55 diameters will throw some light on this.

FlG. 4 —Lateral and coronal aspects of enamel organ and adjoining tissues, x 55 (circ.).

In this photograph I would point out that the layers which I have called the
external epithelium and the stellate reticulum—the last rapidly disappearing
remains of which are found at the coronal aspect only, become condensed in
their course down the sides of the tooth. The stellate cells disappearing, the
external epithelium continues as a fairly definite layer of cells, which persists
throughout the whole extent of the enamel organ, elongated and flattened,
though not to the same extent as at the coronal aspect, which is what would be
expected. But in those parts where manipulation has separated the follicle
from the enamel organ (see also fig. 5) this layer has remained attached to the
follicle, but still is differentiated from the remaining cells of the follicle—just
in the same way as the several layers of epithelium which are the ultimate
remains of the enamel organ are found lining the normal adult tooth follicle,
and eventually go to form Nasmyth’s membrane.

Sprawson: Enamel Organ of Felis domestica

Further, the lateral cells of the follicle, where growth is comparatively
slow, have the thinned-out appearance usually associated with and possibly
due to condensation ; but those cells which I have called stellate reticular cells
have by no means this appearance, though growth being most active at that
point where they are seen, one might well expect the evidence of condensation
to be at its maximum in this position. Moreover it is not usual, as far as
I know, to find two such different types of mesoblastic cell, or in two such
definite layers composing the tooth follicle, and, in addition to this, avascular.
It is also well known that immediately external to the enamel organ, and
frequently emitting many capillary loops dipping into the external epithelium,

Fig. 5.—A portion of fig. 4, but x 455.

there is a very dense vascular plexus, which, I presume, is represented in these
slides, external to the enamel organ layers as I have named them ; if these
layers really represented the follicle there is no reason why this plexus should
be so totally excluded from it, as it rather definitely is.

I mentioned earlier the great variability in appearance of the follicle in
various stages of growth ; this is confirmed by the next slide (tig. 6), which
is a photograph of a section of another portion of the same tooth. Here it will
be seen that the outer two layers of the enamel organ have entirely disappeared
and that the developing tooth is very closely approximated to its deciduous
predecessor. Very active absorption must obviously be going on, yet the

Section of Odontology

5 a

vascularity of the part external to the remains of the enamel organ is poor,,
compared with the vascularity shown in the other slide. I think one may
conclude therefore that the outer vascular ploxus shown in fig. 1 is that
situated, normally, immediately external to the enamel organ, and that therefore
the two layers are as I have named them. One might almost say that at the
point shown in this slide the follicle hardly exists at all, it is so thin; in life
the measurement from the ameloblasts to the dentine is rather less than in.,,
and this area includes the stratum intermedium and absorbent organ layers.
Incidentally this slide rather aptly illustrates a point I emphasized in
describing the pathology of dentigerous cysts, for here, in this very narrow
and confined space, might be found epithelial cells : (1) from the coronary
portion of the permanent tooth follicle, (2) from the sheath of Hertwig of

Fig. 6.—Part of the same enamel organ as shown in figs. 1-5, but at a later stage and
nearer deciduous predecessor, x 50 (circ.).

the deciduous tooth, and (3) from the tooth band. Considering how condensed
they are at this point, I do not think anyone can say from which of these
three possible origins any epithelial growth in this region of the apex of the
deciduous tooth really starts, for besides being condensed it is not stationary,
but moves with the erupting tooth.

In describing the external epithelium of the enamel organ, Mr. Howard
Mummery [ll says that these cells

in later stages are often elongated, their axes lying parallel to the surface. The cells of
this layer merge into those of the stellate reticulum.

This I think is shown. Still, one must bear in mind that he also
says [1] :—

54 Sprawson: Enamel Organ of Felis domestica

There is little doubt that many preparations said to show blood-vessels in the
stellate reticulum, really showed them, not in this layer, but in the connective tissue
outside the enamel organ, which, when the stellate reticulum has disappeared, lies
in contact with the stratum intermedium and often very strongly resembles it in
appearance.

It must, however, be admitted that the layers in these slides seem fairly
well differentiated. Vascularity of the enamel organ has been described in
varying extent in several species of marsupial by Marett Tims and Hopewell
Smith L2], by Thornton Carter [3], and by Bolk [4] ; in a monotreme and a
rodent by Poulton [5], and in a foetal ungulate by Broomal and Fischelis [6],
In all the foregoing instances capillaries were described as penetrating the
stellate reticulum, but only to its full depth, or beyond, and into the stratum
intermedium, in the case of the two marsupials Macropus rufus and Phasco -
larctus cinereus.

More recently Addison and Appleton junior [7] have described vascularity
of the enamel organs of the molars of the albino rat, and the photomicrographs
they show are in many respects similar to those I have just shown. These
authors find that vaspulapty is most marked at the coronal aspect where the
stellate reticulum is thickest, and that it becomes' more S ifitense as the active
development of the enamel approaches its maximum. This appearance seems
to be somewhat similar to what is seen in Felis domestica , except that vessels
cannot be found in the.young enamel organs of this animal at all; they would
seem to be a later development only.

REFERENCES.

[1] J. Howard Mummery, “The Microscopic Anatomy of the Teeth.” [2] H. W. Marett
Tims and A. Hopewell Smith, “ Tooth Germs in the Wallaby, Macropus mlliardieri ,” Proc.
Zool. Soc. t Lond., 1911. [3] J. Thornton Carter, “The Cytomorphosis of the Marsupial

Enamel Organ,” Phil. Trans. Boy. Soc. [4] L. Bolk, “ Ueber ein Geoiss mit vaskularisierten
Schmelzorganen,” Anat. Anz. y 1915. [5] E. B. Poulton, “True Teeth and the Horny Plates of

Ornithorhynchus,” Quart. Journ. Micr. Sci. y 1888. [6] J. Norman Broomal and Philipp

Fischelis, “Anatomy and Histology of the Mouth and Teeth,” 6th ed. [7] William H. F.
Addison and J. L. Appleton, Jr., “ The Vascularity of the Enamel Organ in the Developing
Molar of the Albino Rat,” Amer. Journ. of Anat. y 1922.

Section of ©OontoloG^.

President — Mr. W. R. Ackland, M.K.C.S., L.D.S.Eng., M.D.S.Brist.

Two Odontomes.

By Professor Arthur Hopewell-Smith, M.R.C.S., Sc.D.

(A) A Compound Follicular Odontome or Compound Composite

Odontome.

Of the two odontomes about to be described the first belongs to a type
which is familiar to the general and dental pathologist, in that it probably
represents a good example of a compound follicular odontome, or a compound
composite odontome according to the classification of the British Dental
Association’s Special Committee. I am indebted to Mr. A. R. Walker, of
Brisbane, for the specimen.

Fig. 1. Fig. 2.

Figl.—Before operation. Shows above, the unerupted permanent canine, below, the
deciduous canine, between, the denticles in situ.

Fig. 2.—After operation.

The clinical history states it occurred in the right maxilla of a girl aged 14.
The deciduous canine had been unduly retained, a bony prominence over the
position of its unerupted permanent successor marking the site of the odontome.
The left permanent maxillary canine was fully erupted, and in normal align¬
ment with the dental arch.

A skiagram of the jaw disclosed the presence of the permanent right
canine. Between it and the deciduous tooth were shadows indicating
abnormal formations of apparently dental tissue (fig. 1). The deciduous tooth
Ar—O d 1 [Juiui 25, 1923.

Hopewell-Smith: Two Odontovies

was removed, the cyst opened up (fig. 2). The contents consisted of fluid and
a congeries of small denticles “implanted in a rudimentary kind of bone.”

Seven in number, the denticles conform generally in shape with definite,
primitive tooth forms reproduced on a miniature scale. Unlike the 500 osseous
masses found by Sir John Bland-Sutton (Transactions of the Odontological
Society , vol. xx), in the right antrum of a girl, aged 11, or the 109 denticles
described by Mr. Ward Cousins in a paper in the British Medical Journal of
June, 1908, taken from the jaw of a boy, aged 11, situated in the region of the
second right mandibular molar, they more nearly resemble those observed by
Mr. A. A. H. Johnson in a case recorded by him in the Proceedings of the
Boyal Society of Medicine (Section of Odontology) vol. iv, and more recently
by Mr. Gerald Harborow three years ago.

Owing to their small dimensions I have considered it inadvisable to make
sections. It is probable, however, that each is composed of enamel, dentine,
and cementum. It was impossible to measure them with any degree of

/ d

Fig. 8 . —Denticles removed from cyst.

accuracy, but their weights, as computed by Mr. Frederic James, are as
follow: (a) 0*0342 grm., ( b ) 0*0542 grm., (c) 0*0218 grm., ( d ) 0*0090 grin.,
(e) 0*0298 grm., (/) 0*0312 grm., and (g) 0*0266 grm. (fig. 3).

(B) A Radicular Odontome.

I have to thank Dr. Edward C. Kirk for submitting to me the second
odontome for examination and report. It had been sent to him by Mr. E. C.
Stephens, D.D.S., of Choteau, Montana, into whose possession it originally
came, to whom my thanks are also due.

The clinical history notes that the tumour was removed from the jaw of
a girl, aged 8, who presented a hard swelling on the left side of the mandible
in the neighbourhood of the deciduous molars. Six months before the
operation there had been no noticeable distension of the parts, but the second
deciduous molar had become so loose that the child unsuccessfully tried to
force it out with her fingers. No pain was complained of.

In operating, infiltration anaesthesia was employed, an incision made

Section of Odontology

through the “ gums and periosteum from the crown downwards/’ and these
retracted on both sides. The tooth with growth was easily detached, being
connected to the mandible by “ fibrous tissue at its base.” The cavity was
curetted, surgically treated, and the gingival tissues stitched together.
“ It readily filled and healed without complications.” No skiagram was
obtained.

The odontome exhibits the constricted neck and divergent roots of a
typical carious deciduous molar with a large, hard, rounded, lobulated, fairly
smooth mass attached to its roots. The relationship of the growth to the
tooth is excentric. Its greater part is anterior, the distal side being free
except at the extremity of the root. Both roots are exposed, the anterior
slightly, the posterior on the distal side very greatly. The colour of its

Fig. 4.

Fig. 5.

Fig. 6.

surface is grey-brownish, this being due to the discoloured, very thick and
tough fibrous capsule (figs. 4, 5).

Its greatest dimensions measure 24’5 mm., its smallest 15 mm. The
dimensions of the crown of the tooth are: Length, O’lO mm.; breadth,
0'8 mm. ; and height, taken from the neck to the extremity of the highest
cusp, 5 mm. The tooth appears to be a member of the deciduous series, and
the above measurements correspond more or less with those which obtain in
ordinary conditions.

The mass is solid, hence it cannot be considered to be a dilated composite
odontome. On sections being made it is seen to be of fairly uniform texture
with a central more heavily consolidated portion—a fact well brought out by
the skiagram. Its upper part extends between the roots of the molar, with
which it appears to be continuous (fig. 6).

58 Hopewell-Smith: Some Observations on the Dental Pulp

The causation and pathology is difficult to determine. Wedl, in his “ Atlas
of the Pathology of the Teeth,” gives drawings which resemble this odontome
more closely than any other that I have found in dental or surgical literature.
In his case a deciduous mandibular right canine and first molar were ex¬
tracted from the mouth of a boy aged ll£. These consisted of a large,
hard mass which microscopically was seen to be composed of a dentine-like,
calcified material uniting the roots of the two teeth. It was evidently not
considered to be made up of hyperplasic cementum, nor was there any
osseous ankylosis present.

The same applies to the case under notice. The absence of pain so
definitely stated in the history of the case, rules out the evidence of any
reactions of an inflammatory nature. The mass may have been occasioned by
an overgrowth of vestigial remains, but in the present state of our knowledge it
is impossible to say.

Some Observations on the Histology, Physiology
and Pathology of the Dental Pulp.

By Professor Arthur Hopewell-Smith, M.R.C.S., Sc.D.

PROBABLY no subjects in the field of research have engaged the attention
of the writer more than those of the minute anatomy, functions and diseases
of the dental pulp. It might be conceived, from the title of this paper, that
it was his intention to review the investigations made by himself and others in
the structure and morbid conditions of this organ. Limitations of time
exclude such an attempt. But while it is advisable to mention some facts
already known, it is now necessary to bring modern knowledge to bear upon
certain questions, and, by careful evidence and precise inference, to set forth in
as concise a manner as possible some recent observations regarding it.

These remarks refer to the dental pulp of man, in many respects unlike
those found in the mammalian lower vertebrates. Comparison between the
two, for instance, shows some dissimilarity in the anatomy of the blood-
vascular systems, and the extent and distribution of the nervous apparatus.

Omitting references to the teeth of fishes and reptiles, it should be noted
that the pulps of the carnivora , herbivora , and rodents deviate considerably
from that of man, and possibly of the anthropoid apes. These variations are
not confined to anatomical characteristics only, but apply equally to function.

(I)

(A) Its Histology.

Mesodermic in origin, and formerly incorrectly described as resembling the
structure of Wharton's jelly, the pulp is a community of connective tissue
elements which are embedded in a transparent and slightly granular basic
substance, retained in a delicate reticulum, partly formed by the interlacing
processes of the cells themselves, and partly by numerous anastomosing inde¬
pendent connective tissue fibres, the peripheral parts of which bind the organ
loosely to the dentine. Yon Korff [l] especially studied these attaching fibres.
I had previously noticed them, but did not emphasize their importance.

Section of Odontology

Occupying a cavity from which it is easily detached, the confines of which
are composed of a unique calcified material, the tissue may reasonably be
remotely compared with marrow, or soft tissue in the larger and smaller
medullary spaces of bone. When the apical foramen of dentine—the homo-
logue and analogue of the nutrient foramen in bone—is formed, the
pulp does not disappear but remains in situ , and one of its functions—the
building up of primary dentine—ceases. There is no evidence that in normal
circumstances it continues to enclose itself in an ever-increasing thickness of
dentine, but in nutritional and other disturbances this is a reaction which is
constantly in operation.

(B) Its Cells.

Of all the cellular elements the most remarkable are those units of what
was originally designated the membrana eboris —interesting not only on account
of their extraordinary morphology, but also because they have excited some
controversy as to their actual function.

Fifty-three years ago Waldeyer [2], writing in Strieker’s 11 Histology,”
called attention to these surface cells which differed in their histological
features from the other constituents of the tissue. Probably conceiving some
distant analogy between them and the enamel-forming cells, then called
adamantoblasts, he named them “ odontoblasts/* a term freely adopted and
used to-day.

The Anatomical Term , “Odontoblast ,** a Misnomer .

It isobvious that, both etymologically and physiologically, this is incorrect—
the word a misnomer. The dental structures are not the product of the same
type of cell: ectoderm and mesoderm are both involved in their genesis.

In view, therefore, of the fact that a so-called odontoblast is not a tooth-
former, as is implied, but is, without equivocation, the parent of the dentinal
fibril which extends into each dentinal tube, I have for some time past entirely
discarded the name, and introduced into dental histology, as more exact, the
word“fjbrilloblast.” Further, regarding its function, observations point to it
not being concerned in the formation of the matrix of the dentine. The
fibrilloblasts, then, call for special notice and description.

The Fibrilloblasts.

Details regarding their shape, size, structure, relationships, have been fully
given elsewhere and need not be repeated. Some full statement, however,
roust be made of further new studies concerning them.

Their number may be approximately computed. For as every fibrilloblast
usually furnishes each dentinal tube with one protoplasmic peripheral process,
and as the number of these tubes has been ascertained, a numerical estimate
roav now be recorded.

If dentine be examined in cross section in investigating the proportional
occurrence of tubes in given microscopical fields, and in given areas in these
same Helds, it is as easy a matter to enumerate them as they appear in circular
outline in one one-hundredths or one four-hundredths of a millimetre as it is
to determine the ratio of erythrocytes in a normal blood count. Bomer [3]
has done this. I, too, have examined material to this end, and have found
that on an average six or seven may be recognized in the former area—an
observation checked and confirmed by one of my experienced laboratory
assistants. Thus by a simple calculation it is evident that there may be no

60 Hopewell-Smith: Some Observations on the Dental Pulp

less than 600 in a square millimetre, that is 60,000 in a square centimetre.
Homer's figures are very much greater. He states that in a very densely
distributed part of human dentine he has seen ninety-four in one four-hundredths
of a millimetre, that is as many as 37,600 in one square millimetre, or
3,760,000 in one square centimetre.

It may therefore be surmised that certain regions of the dental pulp are
covered with fibrilloblasts the numbers of which range between these figures.

As it is a matter connected with the determination of their function it
must be remembered that they are highly specialized cells, different in every
particular from the ectodermic epithelial ameloblasts which construct enamel,
and the mesodermic osteoblasts which fabricate bone. Ameloblasts are long,
cylindrical, regularly-arranged units, with conspicuous basal processes (Tomes’s
fibres), held together, as in the case of all epithelia, by means of a minute
amount of intercellular substance. The latter are round, square, oblong, or
oval in form, also possessing short processes. Of about the same dimensions
they become, during bone formation, the bone cells, occupy the lacunas in that
tissue, and remain in continuity with each other through the medium of their
processes which traverse the intervening canaliculi.

The Fibrilloblast Forms the Dentinal Fibril and not the Matrix of Dentine.

Each fibrilloblast possesses a very special peripheral process extending
probably, but not with absolute certainty, through the greater part of the
width of the dentine. As the coronal fibrilloblasts are larger than the radicular
cells ; as they vary in size when seen microscopically in sections cut in the
same plane, being larger in the greater and shorter and smaller in the lesser
diameters, it follows that not only in their diversities of size, but also in the
variations of the lengths of their distal processes they are not anatomically
comparable with osteoblasts. Fibrilloblasts vary from 5 to 3 microns in width
and from 25 microns to 8-10 microns in length. Osteoblasts maintain, more
or less, a uniform size. Hence it is permissible to assume that the physiological
activities of the two are widely different and that the former perform a higher
function than the latter.

Sir Charles Tomes is of the opinion that the primary function of the
fibrilloblast is to keep patent the lumen of each dentinal tube and with this
I fully agree. Each cell thus allows tissue fluid or lymph, filtered from the
capillary or pre-capillary circulation, freely to penetrate the tube around its
peripheral process. Metabolic and other vital processes taking place in the
cytoplasm and karyoplasm of the cell endow the fibril with similar properties.

Dentine is not Innervated.

No evidence has been completely established to prove the presence of any
structure other than the fibril, or any fluid other than lymph in the dentinal
tube. It is too minute even at its largest pulpar extremity to accommodate a
single red blood corpuscle. Blood never extravasates into dentine, but in certain
circumstances plasma and the products of haemolysis may do so with sub¬
sequent and inevitable discoloration of the parts.

This tissue is destitute of nerves, although appearances which may be
interpreted as nerves are easily produced, by following certain methods of
microscopical technique.

Many evidences, however, of a clinical, physiological, histological, and
pathological character are forthcoming—if sought for—to show that dentine

Section of Odontology

is not innervated. To take two only out of more than a dozen: If one or
more nerves occupied each tube there would, of necessity, be between 600 and
37,600 in every square millimetre of human dentine, including the radicular
as well as the coronal regions—a two-fold mistake on the part of nature, first,
in that dentine would be rendered more receptive of sensory impulses than the
exquisitely sensitive cornea or conjunctiva or nasal mucous membrane, and
secondly, that it would contain a nervous mechanism wholly illogical, un¬
required, and absolutely unlike that of any other part of the body. Calcified
material is not innervated : bone contains no sensory nerves whatever. They
would serve no useful purpose there or in dentine or enamel.

Another illustration may be given. It is a well-known clinical fact that
the formation of carious cavities in teeth with living pulps may be absolutely
unattended by pain or other subjective sensation on the part of individuals.
The usual prodromata of nervous disturbances in the pulp associated with
dental “ caries ” are frequently entirely wanting. If nerves were present in
the hard dental tissues this could not possibly occur. The excavation of a
cavity most commonly produces pain in consequence of pressure on the in¬
elastic columns of intratubular material and the softened (decalcified) inter¬
tubular matrix of the dentine transmitted to the surface of the pulp. The
character of the pain varies according to the depth of the excavation and
the amount of pressure used by the operator in removing the carious parts.
It is inconceivable that this would be the case if nerve fibrils traversed the
tubes of the parts involved, for then the intensity of the pain would be similar
throughout their whole length.

The concept of the innervation of enamel and dentine may be traced to
German sources. One of the original exponents of the theory has long since
modified it. It can only be briefly told how Morgenstern [4] supposed that
myelinic nerves entered the dentine in special tubes (which apparently existed
only in bis own preparations) and passed into the enamel; how Romer [5],
twenty years ago, believed that sensory nerve fibres pierced the fibrilloblasts
and ran up into the dentine and enamel “ splindles ” in the interior of their
processes, which is contrary to any anatomical relationships in other parts
of the body; and how Dependorf [6] described nerve fibrils in the matrix as
well as the tubes—an impossible condition. It is significant that, of the above,
Romer [3], in his last publication, recedes from this position, considering, and
with good reason, that what he had previously described as nerves were, as a
matter of fact, artefacts. In describing the nervous system he writes:—

“ The nerve fibres lose their medullary sheath, and end, for the most part, in and
Wow the odontoblastic layer. ... I did believe, in former years, that a part of the
non-medullated nerves penetrated into the dentinal tubules. At present, however, I
am doubtful about this conception. 1 ’

Dentine Insensitive .

Regarding, therefore, the question of the so-called sensitivity and “ hyper¬
sensitivity” of the dentine with the utmost impartiality and absence of
preconceived ideas, and analysing it by the most direct methods and with the
widest vision, I do not feel justified in accepting as correct the evidences so
far presented. I have come to the conclusion that this tissue, being nerveless,
cannot be, per se , sensitive, though capable of conducting or transmitting, by
reason of its unique physical and anatomical characteristics, thermal, tactile,
surface tension and electrical impulses to the pulp. I am convinced that this

62 Hopewell-Smith: Some Observations on the Dental Palp

admits of irrefutable proof, and that it is the one and only interpretation to be
placed upon the exhibition of certain physical phenomena; and my teaching is,
therefore, firmly based on this deduction. A closer and fuller analysis of the
whole subject is, meanwhile, reserved for another occasion.

When the fibrilloblast has fulfilled its r6le of elaborating a fibril from its
cytoplasm, it begins to undergo morphological and physiological changes, and
from being a large, somewhat columnar cell, shrinks considerably in size
and merely maintains sufficient vitality to prevent complete stenosis of the
lumen of the dentinal tube. Adult fibrilloblasts are distinguished micro¬
scopically from young cells by their changed form.

Two further observations concerning the fibrils may be made. Some
writers, particularly those of the German school, regard them as being hollow.
Such are the vagaries of optical refraction and of microscopical technique that it
is not difficult to demonstrate their apparent tubularity. But no animal cell
affords a parallel. A fortiori it can be stated that these functionally insignificant
and moderately useful cells do not differ from other connective tissue elements
elsewhere, and that their processes are solid and not in any sense canalized.

The length of the unbranched fibril, enormously out of proportion to that
of the cell from which it emanates, may in the coronal parts of the dentine
perhaps measure one hundred and fifty times the length of the fibrilloblast—in
histological calculations as twenty-five microns to five millimetres. This fact
alone renders the fibrilloblast and its process quite distinct from any other cell
in the human body except the neurone, and at once raises it to a position of
far greater importance than that of merely forming dentine matrix, which has
hitherto been the more-or-less generally accepted theory.

Hastate Cells.

With the exception of a frequently-recurring type hitherto undescribed,
shaped like a spear head, to which I have given the name “ hastate,” the other
cells of the pulp need not be mentioned.

The uncommon nature of the blood-vascular system is of importance when
the main function of the pulp as a whole is considered. So minute are the
vessels that they are correctly described as arterioles, venules and capillaries.
In section, the first named are recognized by their small size and the thick
tunica adventitia composed of connective tissue and elastic fibres, the media
being reduced to delicate ribbons of circularly-disposed involuntary muscle
fibres. In the pre-capillary arteriole there is no musculature.

The large, thin-walled venules are provided with an inconspicuous middle
tunic which renders them less contractile than the arterioles. They retain
their circular outlines and do not collapse, as is the case with most other
tissues. They are destitute of valves like those of yellow and red marrow
of bone, and copy on a small scale in this anatomical feature the venae cavae ,
cerebral, pulmonary, portal, hepatic, renal, facial and other veins. This
valveless structure is a highly predisposing local factor in the production of
nutritional diseases of the pulp, as obviously the vascular circulation is slowed
down and there is a great tendency to the induction of venous or passive
hyperaunia.

. Conforming to the usual type, the capillaries consist of a single layer of
endothelial cells. They are very abundant near the dentine, obviously to
supply it effectively with lymph.

Section of Odontology

(D) Its Nervous System.

The myelinic (non-medulla ted) nerve fibres in modern man are cellulipetal.
Constituting the peripheral axones of receptive afferent nurones, they are
essentially the distal teleodendrites of the peripheral sensory neurones, entering
the pulp at the apical foramen of the teeth in company with the blood-vessels
and terminating somewhat similarly to the ordinary sensory nerves, not in
special anatomical formations as described by Mummery [7], but in minute
endings around the fibrilloblasts on the anatomical threshold of the pulp.

(E) Its Anatomical Peculiarities.

The extraordinary, interesting and important anatomical features of the
human pulp may be briefly summarized as follows:—

(1) Absence of a collateral arterial circulation, which tends to nullify any
attempts at reparative action or healing of parts or individual regions of
the tissue.

(2) The great number, large size and valveless character of the venules,
factors contributing to probabilities of regurgitation of blood and the production
of venous stasis and hypereemia—a very common condition, terminating
more or less in thrombosis, degeneration, calcification, and inflammation.

(3) Inexistence of a definite lymphatic system, which would otherwise
assist in removing inflammatory exudates and waste products. Lymph spaces
abound everywhere, but no organized system is satisfactorily demonstrable.

(4) Absence of direct nervous control over its environment.

(5) Its unique mural limitations, which thus favour injury through the
accumulation of transudates and end products.

(6) Its constant subjection to rapid and extreme changes of temperature.

(7) The early completion of formation of the apical foramina of the
dentine, thus shutting off nutritional sources and favouring local haemostasis.

To the above there may be added two abnormal conditions which act as
local predisposing causes of disease, viz., (1) the frequent presence of fillings
in enamel and dentine which may be thermal conductors and affect the
physical properties of the hard tissues ; and (2) the constant presence of
adventitious dentines which, slowly accumulating, thus diminish the cubic
capacity of the pulp cavity.

(II)

Physiology.

Formative and Nutritional Functions of Pulp .

From a comprehensive study of the comparative anatomy of the dental
pulp the conclusion must perforce be reached that its main, if not its sole,
uses are: formative and nutritional.

In its early phase as the dentinal papilla it is concerned in building up the
calcified material which ultimately nearly completely surrounds it. This is
accomplished, similarly as in the case of bone, by small cells of an osteoblastic
type, the activities of which are directed towards the abstraction of the
necessary salts from the blood and deposition of the same around dentogenetic
fibres, which form the scatfolding of the dentine. Once its main energies are
concluded, it merely exists to provide a source of modified form of nutrition
for the dentine—again from the contents of the blood-circulatory system.

64 Hopewell-Smith: Some Observations on the Dental Pulp

Lymph exudes from the capillaries and pre-capillaries and passes into the
dentinal tubes for the purpose of keeping the matrix moist, and not to vitalize
it in the fullest meaning of the term. Dentine is not alive, nor is it wholly
dead like enamel. It serves as an intermediate tissue between the dead enamel
externally and the living pulp internally. It does not generate sensations but
transmits through its tubes impulses of various kinds to the pulp. That is one
of the reasons why it is tubular. It is essential for the strictest requirements of
the animal economy that dentine should remain moist. For, subsequent
to its drying out, it shrinks, and the enamel—an inorganic, dead, solid,
inert, calcified secretion, unable to contract, incapable of being influenced by
metabolism—beomes cracked and thereby impaired. The dentine of a pulpless
tooth becomes slowly desiccated and the enamel frangible and fissured.

If the pulps of the lower vertebrates be specially examined the scanty
distribution of myelinic nerves can be soon determined. A sensory equipment
is not required to such a great extent as in man, for the teeth of the
domesticated animals, as well aa those living in ferd naturd are not and
cannot be subjected to the same thermal, chemical, pathological and physical
changes which obtain in the human oral cavity.

Domesticated Animals do not Experience Odontalgia .

Cats, dogs, pigs and other domesticated vertebrates do not suffer from
odontalgia when the pulp happens to become exposed either by. traumatism or
“ caries.” Extensive cavities may develop, with no obvious symptom of dis¬
comfort or pain. The sensory susceptibilities of these pulps are very limited in
range of action—if they exist at all. Vasomotor nerves distributed to the coats
of the blood-vessels predominate, and maintain normally very definite and well-
balanced trophic influences on the parts.

It would appear reasonable to postulate that the sensory apparatus in man
is concerned with translating the various forms of stimulation just mentioned
into the special sense of pain, the sympathetic system being only associated
with the vasomotor mechanism of the unstriped muscle fibres in the walls of
arteriole and venule. The sensory nerves do not possess any discriminative
sensibility.

It may further be safely affirmed that this unusual, somewhat extensive
supply is a sign of a process of evolution, in which a defensive machine has
been developed and permanently established to meet the singular needs of
modern human dental organs. For prehistoric man, as revealed by skiagrams
of the molars of the Krapina and Mauer mandibles, possessed pulps of
a relatively larger size than those of present day individuals. As his jaw in
the course of several chiliads became smaller, the dimensions of the teeth
diminished, and the pulp chambers greatly reduced, the sensory nervous supply
in the meantime evidently undergoing concomitant increase in the development
of its exquisite perfection of distribution and importance. The perception of
pain—the latest of the senses to be evolved—was intensified at the expense of
the cubic volume of the whole organ to meet the newer and more complex and
delicate necessities of civilization.

The chief operations of the fully-formed pulp in the lower animals would
seem to be restricted to the supplying of dentine with lymph, thus keeping it
moist and nourished. The human pulp, while possessing a similar function,
is, in addition, a sentient organ, its nerves in their immediate response to
various kinds of stimulation acting as a defensive, monitory and protective

Section of Odontology

mechanism. Of these two functions, however, the nutritive factor is the more
important, and the pain-producing and pain-conducting properties of con¬
siderably less account.

The sensitivity of the human pulp diminishes as age comes on, not because
of an increase in density or dimensions of the dentine, but because of intrinsic
retrogressive metamorphoses of an unalterable character in itself. The pulps
of the deciduous teeth exhibit old age changes exactly on similar lines with
those of the permanent dentition.

(HI)

Pathology.

The welfare of the enamel and dentine depends on the life of the pulp.
After it has been destroyed either intentionally or by morbid conditions, the
tooth becomes a foreign body and is liable, especially if the alveolo-dental peri¬
osteum is implicated by disease, to be exfoliated as a menace to the well-being
of the body generally.

Threatened exogenetic disturbances will be resisted by the pulp in the mouth
of a healthy person, and attempts will be made on its part, even in the cases of
those suffering from general malnutrition and long-continued fevers, to attain
the same end.

It may be stated that any acquired changes of a pathological nature that
may occur in the hard tissues will act upon the soft tissues, which will respond
more or less speedily, either by a definite demonstration of adding a thicker
wall to the dentine at the point of attack, or by becoming hypersemic or
inflamed, or both. If the injury is slight, new protective material is laid down ;
if severe, the unequal contest ends in active hyperaemia and localized inflam¬
mation on the one hand, or in venous hypereemia and thrombosis and
degeneration on the other.

Reactions due to Non-operative Injuries.

Resistance is well exemplified in the attemps of this organ to counteract
the effects of the centripetal lesions of attrition, erosion, abrasion, true
caries, and the bacterial affection of enamel and dentine known as “ dental
caries.”

If teeth which have undergone attrition be examined in longitudinal
section it is evident that a large amount of secondary dentine has been
deposited by the cells of the pulp opposite the area of attack, viz., its
coronal and cornual regions. By this means the total bulk of the pulp is
considerably diminished. In erosion and abrasion, adventitious dentines,
the results of reaction to injury, are invariably present.

With regard to “ dental caries ” the pathological phenomena are consist¬
ently more complex, for, shortly after its inception, the pulp, as usual,
attempts to defend itself by precipitating on the threshold of its threatened
surface one or more varieties of adventitious dentine which I have described
in detail elsewhere [8]. Thus the areolar, cellular, fibrillar, hyaline, laminar,
and tubular types may be observed, the particular kind being probably
dependent upon the rate of progress of the infection and the rapidity of
response on the part of the pulp cells. If acute, the first named are most
frequently noticed, if slow and chronic the latter varieties.

In spite of the attempts of the pulp to heal the lesion its energies are
usually unavailing, for the new adventitious dentine often becomes likewise

66 Hopewell-Smith: Some Observations on the Dental Pulp

infected and a hyperaemia of the soft subjacent organ thereby induced. (See
figs. 1-4. Vertical sections of dental pulp in situ , which exhibit four phases of
the process of infection of the adventitious dentine in one of the cornua of the
pulp cavity, the usual condition associated with deep-seated dental “ caries.”)

Adventitious Dentine of Pathological Origin.

It must be noted that while it invariably reacts in the best possible
manner to the above-mentioned injuries as an auto-defensive measure, its
object is frequently defeated. For the mechanical addition of layers of

Fig. 1.—A, primary dentine; B, adventitious dentine slightly infected; C, fibroid
fibrilloblasts ; D, junction of primary and adventitious dentines.

adventitious dentine, or secondary dentine in the case of attrition (the last-
named formation being physiological in contradistinction to being pathological
in origin) means (l) the gradual reduction of the cubic capacity of the pulp
cavity ; (2) a restriction in the complete and perfect use of the physiological
activities of its containing organ ; (3) the limitation of its powers of healing;
(4) an increase in its difficulties of overcoming the advancing destruction;
and it ends in the lowering of the vitality of the issue to such an extent as to
bring about a general predisposition to degeneration and inflammation. Also,
all these changes are profoundly affected by the more or less complete centri¬
fugal stenosis of the apical canal, which is of so common an occurrence

Section of Odontology

through hyperplasic cementum becoming deposited about its orifice. In
addition it means a lessening of the trophic influences which it brings to bear
primarily upon dentine and indirectly upon enamel. In a word, the fantastic,
universal, well-intentioned exertions made by the pulp to repair damage are
practically always doomed to failure on account of the anatomical peculiar¬
ities of its own surroundings in particular, and its immediate surroundings in
general. Singular to relate, it is killed by the defensive measures it adopts to
combat the disasters that may befall it!

Fig. 2.—A, primary dentine; B, infected adventitious dentine; C, pulp nodule.
Pulp is fibroid and hyperiemic.

Diseases of the Pulp.

It is not surprising that the pulp is so frequently a victim of disease when
the numerous causes are taken into consideration. They may be classified as :
(A) predisposing, and (JB) exciting causes.

(A) Predisposing causes may be divided into : (l) general and (2) local.
The general predisposing causes may shortly be stated as follows: (1) Sex, (2)
age ; (3) marasmus (general nutritional failure), and (4) protracted fevers.

Of these the first has probably little influence on causation. But age
appears to determine pathological conditions very largely. In general terms
one may say that up to the age of 20 to 25 the pulp is in a normal state.

68 Hopewell-Smith: Some Observations on the Dental Pulp

After the age of 30 it is by no means always normal, being dependent upon
the partial or complete stenosis of the apical canal and foramen. With regard
to trophic neuroses and fevers the pulp suffers in the same way as other parts
of the body. That the general welfare and health of the teeth is dependent
upon the general health of the body is an incontrovertible axiom.

The local predisposing causes are found in the anatomical peculiarities
already reviewed.

(B) The exciting causes may be (l) general, due to (a) vascular disturb¬
ances such as increased or diminished blood-pressure, or chemical constituents

Fig. 3.—A, primary dentine; B, infected and broken down adventitious dentine;

C, fibroid pulp.

of the blood; (b) nervous disturbances, ascribed to affections of the sensory
and sympathetic nerves, and (2) local, bacterial invasion of the dentine.

Reactions due to Diseases of the Pulp .

Arterial and venous hyperaemia, followed by fibrous and calcareous
degenerations as well as inflammation, are the direct reactions of the pulp to
pathological conditions to which it is subjected during the course of “ dental
caries.” In other words, infection of the dentine in its later stages produces
the vascular changes just named. Of these, venous or passive hyperaemia is
more usual than active or arterial hyperaemia for the reasons already recounted.

Section of Odontology

The histological phenomena observed here are identical with those seen
in similar circumstances in all soft tissues. They are, however, modified by
the rigid enclosure of the walls of the pulp cavity, by the lack of collateral
circulation and the peculiarities of the venous system. It is, therefore, quite
a common experience to find thrombosis going on in such a pulp. Indeed, in
many, perhaps even the majority of the pulps, thrombi readily form in the
veins, small haemorrhages take place and the integrity of the parts becomes
Completely undermined and destroyed, either by the production of a fibroid or
calcareous degeneration, generally with the formation of pulp nodules, or, if
the injury is very great, infection, gangrene and death.

Fig. 4.—A, primary dentine; B, carious primary dentine; C, large cavity in
adventitious dentine; D, pulp nodule; E, slight inflammation of pulp; F, inflamed
nerves.

Fibroid Degeneration Extremely Common in Adult Life.

Fibroid degeneration is very general, not only in senile conditions and
pulps affected by “ caries,” but in non-carious teeth of adult and young alike.
Without entering into detail—there is no time—it may be stated that recent
original observations, regarding this matter especially, tend to show that the
change originates in the arterioles. The muscle fibres of the tunica media of
their coats become more or less atonic ; the velocity of the blood-stream is
lowered; the venous haemostatic pressure increased, with the result that the
cellular elements quickly suffer. Their nuclei shrink, the cytoplasm becomes
atrophied. The fibrilloblasts lose their usual outlines, become “ sheaved ”
together and reduced to attenuated, elongated bodies. The venules become

70 Hopewell-Smith: Some Observations on the Dental Pulp

larger, their walls thinner, and thrombosis and haemorrhages occur. The
sequence of events would be that the arterioles are first affected, then the pulp
cells, then the capillaries, then the venules, and finally the nerve bundles.

Fibroid degeneration is often accompanied by the formation of one or more
varieties of new adventitious dentine. This is deposited in the first instance
at the upper portions of the cornua, is derived in a parallel manner to the old
primary dentine from small lime-depositing cells in a menstruum around con¬
nective tissue fibres, and is exceedingly liable to infection by bacteria from the
primary dentine.

Pidp Nodules Extremely Common.

Pulp nodules are said to be caused by calcification taking place around a
collection of dead cells within the pulp. This is probably not so. It has
never been explained why a few cells, say in the equatorial segment, should
die. If, however, some should die and degenerate, they would at once be
attacked by phagocytes that have migrated from the neighbouring blood¬
stream, acting as defensive agents. Cytolysis would immediately ensue and
the source of the irritant be removed. A similar erroneous claim has been
made with regard to dead bacteria.

Pulp nodules are extremely common, not only in pulps of the permanent
dentition, but also of the deciduous series, in apparently sound teeth, as well
as those affected by so-called dental “caries.” They are most likely due to
venous hypersemia with thrombosis, when great physical and chemical
changes take place in the walls of the vessels. Arising probably in a similar
manner to phleboliths—the local effects of intravascular coagulation—but
incomparable with tonsilloliths—the results of infiltration of mucous secretions,
these concretions originate in the deposition of calcium salts by small round
cells in and around the connective tissue stroma of the pulp. Evidence is not
wanting that the process follows that by which adventitious dentine is
constructed, and that it closely resembles the calcification of the primary
dentine.

Inflammation of Pulp Relatively Rare.

Odontalgia is of three types—simple or local, referred or obscure. The
first is a localized obvious symptom of physical, vascular and nervous
disturbances in the hard and soft tissues, including the alveolo-dental
periosteum. Referred odontalgia is a symptom of a distant affection which
expresses itself as a non-localized irritation of the peripheral parts of the
trigeminal nerve and its connexions ; while obscure odontalgia, on the other
hand, associated with non-carious lesions, is a symptom of an intrinsic or
extrinsic condition in which the vascular and nervous supplies of the pulp are
involved, and the causes of which are not evident on mere visual examination.

Obscure odontalgia is believed to be due to: (A) Intrinsic disturbances:

(1) Increased or diminished intrapulpar blood-pressure, as in influenza,
malaria, and during puberty, menstruation and pregnancy, hysteria, &c.;

(2) variations in the chemical constituents of the blood as in a drop of its
calcium content; (3) formation and growth of pulp nodules. (B) Extrinsic
disturbances: (1) General neurasthenia and debility; (2) intra-oral electrical
impulses; (3) reflexes from the glossopharyngeal and possibly the chorda-
tympani nerves ; (4) osteitis of the alveolar process, e.g., maxillary tuberosity;
and (5) lesions of the fifth nerve.

In none of these is acute or chronic inflammation the cause, and it is

Section of Odontology 71

probable that mere inflammation is rarer than is generally supposed to be the
case.

Conclusion.

To sum up: Taking into consideration the structure and specific uses of
(a) enamel—solid, adamantine, a mechanical agent supremely adapted for the
trituration and comminution of food; of ( b ) dentine, tubular, hard, serving
mainly as a support for the all important enamel, the utility and economic
value of the human dental pulp may now be comprehended and estimated
probably with much scientific accuracy.

Reviewing its histology, functions, and commonest morbid conditions, its
frequent tendency to undergo retrogressive metamorphoses, fibroid or calcific,
and to maintain its vitality at a low ebb, it would seem that its removal as a
surgical operation is of but little moment so far as the ultimate efficiency of
each unit of the dental apparatus is concerned. A pulpless tooth is nearly as
useful a member of the dental series as a living tooth, but not quite, because
of the physical changes which subsequently must occur in the hard investing
tissues when the central organ is destroyed. It would, however, appear to be
desirable that the integrity of the pulp should be retained unimpaired and
efficient; but if this is impossible, then removal from the containing cavity of
a tissue which is seldom capable of adjusting itself successfully to functional
and organic disturbances, and of regaining and maintaining its former useful¬
ness and intrinsic worth to the tooth, mouth, and body generally, may be
regarded not as a serious but perhaps at times even as an advantageous and
successful expedient.

REFERENCES.

1] von Korff, “Die Entwickhmg der Zahnbeingrundsubstanz der Saiigethiere,” Arrhiv. f.
Mikro . Anat., xlviii, p. 1 . [2] Waldeyer, “ Handbuch der Lehre von den Geweben,” 1871. rill

KoMEK, ‘'Atlas der Path.-Anat. Verand. der Zahnpulpa,” 1909. f4! Moroenstern, Archie. f.

Anntomie unit Physiologic, 1896. [5] RoMER, “ Zahnhistologische Studie,” 1899. [6| Dependorf,
Deutsche Monatschr. f. Zahnhcilknndc, 1918, xxxi. F7j Howard Mummery, “ The Microscopic
Anatomy of the Teeth,” 1919. [8J Hopewell-Smith, A., “Normal and Pathological Histology

of the Mouth,” 1918.

[The paper was fully illustrated by means of microscope slides, photo¬
micrographs, and a fine series of original coloured lantern slides.]

Ar—O l> 2

Section of ©bontoloap.

President—Mr. W. R. Ackland, M.R.C.S., L.D.S.Eng., M.D.S.Brist.

A Case of Unerupted Incisors and Canines in a Male,

aged 59.

By Gerald Harborow.

This patient came to me at the Metropolitan Hospital in July last, with
a swelling in the incisor region of the mandible.

Four days previous to his visit he had had great pain followed by swelling,
which discharged later ; after this he had little pain and only slight discharge.

Fig. 1.

On examination there was marked oral sepsis but the only teeth seen in the
mandible'were „ 7 . There was not much swelling now, but a good deal of

bone thickening. There was a foul sinus in the sulcus to the right of the
middle line and this was large enough to simulate a tooth socket. On passing
a probe, bare bone, and what felt like a tooth, could be made out. From
exploration it could be clearly diagnosed that the condition was more than an
O—-Od 1 [April 23, 1923.

74 Harborow: Unerupted Incisors; Mellanby: Caries

ordinary alveolar abscess. The patient was sent for X-ray examination and
a mouth wash was ordered.

The X-ray photograph showed unerupted teeth, four being plainly visible,
but which teeth they were w T as uncertain (fig. 1).

The patient could not supply any definite history ; he was a healthy man
and had had no illness and no trouble or pain with his teeth. He had been
without front teeth for at least twelve years. He remembers having had little
black stumps level with the gum, but these fell out, they were not extracted.

His work necessitates his using a stock and bit, which he rests against his
chin in working it. This has caused some thickening of the soft tissues.

The operation, which was carried out under chloroform and ether anaesthesia,
consisted in making an incision to the full extent of the swelling and cutting
away the outer wall. This did not give a very satisfactory field for operation,
but the teeth could be felt quite easily. They were loosened by the straight

Fig. 2.

elevator and removed with Reed’s forceps. Their removal did not present any
great difficulty. They consisted of the two canines and lateral incisors.
The patient did well and at the end of three weeks I examined him again and
was surprised to find that a tooth could be felt in the cavity. Further X-ray
examination showed two teeth, one almost horizontal, the other leaning over
to the left side. The patient was again anaesthetized with chloroform and
ether and the teeth were removed by the same method used for the others ;
but these caused a considerable amount of difficulty, due no doubt to their
being implanted more deeply in the bone and to their position. On examination
of the teeth it will be noticed that the left central incisor has a curved root
and is undoubtedly the one which was horizontal, the right leaning towards
the left side ; each tooth shows some rarefaction at the root; the canines only
show the thickened cement, which is usual in cases of delayed eruption (fig. 2).

The Effect of Diet on the Resistance of Teeth to Caries.

By May Mellanby.

(Pharmacological Department —University of Sheffield.)

_ In the March number of the Dental Cosmos the following statement occurs
inlthe editorial article :—

“ Dr. Black’s researches led him finally to the belief that caries of the
teeth is a factor of the environment of the teeth, and not of the structural
peculiarities of the teeth themselves ; that structural features may influence

[March 26, 1923.

Section of Odontology

the rate of decay but have no bearing upon the liability of the teeth to decay;
that any tooth will decay in a caries-producing environment and that no tooth
will decay in a non-carious environment. These conclusions are accepted as
sound by all who have intelligently weighed the evidence upon which they are
founded, and no one thus far has brought forward evidence that successfully
rejects them.”

I hope to supply you with evidence which refutes at least some of these
conclusions, and shows clearly, not only that the structure of the teeth plays
an important part in regulating the subsequent resistance of such teeth to
caries, but also that those dietetic conditions which determine the perfect
formation of teeth, are responsible to some extent for their defence against
bacteria and other harmful influences after eruption.

The new facts I wish to bring to your notice concern the question of the
resistance of teeth to caries, after eruption. This is usually assumed,
as in the paragraph quoted, to be a question of the condition of the
mouth and the immediate environment of the tooth, but a study of the
secondary or adventitous dentine in human beings and experimental animals
indicates that factors acting indirectly through the pulp and other tissues are
of dominant importance in regulating this resistance. Before dealing with this
evidence and in order to give sequence to my narrative I will briefly remind
you of the main facts brought out in my earlier published work [1], which has
differed from most other dental investigations mainly in two respects :—

(1) I have attempted to determine the influence of dietetic factors after
digestion on the teeth and jaws. This influence of food seems to have attracted
comparatively little attention in earlier work although the results obtained
prove it to be of prime importance. I have disregarded, for the time being,
the chemical and physical action of food in the mouth and its relation to
bacterial decomposition.

(2) Most of the work was carried out in the first place on animals. In no
other way would it have been possible to determine the part played by each
factor of diet and environment in turn, and by processes of direct observation
and elimination to narrow down the issue to a few of the more important
influences. I feel sure that the animal experimental method will prove to be
of great importance in dental investigations.

The experiments on puppies have shown that the structure of the teeth
and their arrangement in the jaws are closely controlled by the quality of the
diet eaten during their development. The diet must of course contain certain
minimal amounts of calcium and phosphorus, but the retention of these
elements in the body and their deposition in the growing teeth depends on
other factors, the most important of which is a vitamin somewhat similar
in distribution and properties to vitamin A. For the purpose of this paper
I shall refer to the calcifying vitamin as vitamin A, although, as pointed out
in previous papers [1], the two substances have not been definitely shown to
be identical. The quantity of this vitamin necessary for the production of
perfect teeth and jaws is variable, because its activity is influenced by the
amount and type of other substances in the diet, by the rate of growth relative
to the food eaten, by the exercise taken, by the earlier nutrition of the animal
both prenatal and postnatal, by the sunlight experienced during the experi¬
mental period and probably by other factors not yet determined. Thus it is
possible by feeding puppies, during the time of development of the permanent
teeth, on diets sufficient in amount, but defective in quality—and, more
especially, having a deficiency of vitamin A—to produce one or more of the
following defects:—

76 Mellanby: Effect of Diet on Resistance of Teeth to Caries

(1) Thick and poorly calcified jaw bone and alveolar processes.

(2) Irregularity in the arrangement of the teeth, generally most noticeable
in the lower incisors.

(3) Delay in, and retardation of, the eruption of the permanont teeth.

(4) Interference with the calcification of the enamel, which is often either
deficient in amount or defectively formed.

(5) Interference with the calcification of the dentine, which may be either
small in amount, or poorly calcified containing varying numbers of inter-
globular spaces.

(6) The tissues at the gingival margin and the periodontal membrane are
often abnormally developed.

It may be added that defectively formed deciduous teeth can also be
produced in puppies by feeding bitches during pregnancy and lactation on
diets which are abundant from the point of view of energy and also protein,
fat, carbohydrate and salt-content, but poor in quality, and especially in
vitamin A.

Whereas it is comparatively easy to produce the above-mentioned abnor¬
malities by defective diet it is also easy to produce in other puppies of the same
litter perfectly formed teeth and jaws by feeding them on similar diets but con¬
taining abundant vitamin A [1], Another dietetic factor which has been
shown to influence the teeth at least of guinea-pigs, is the antiscorbutic
vitamin. Zilva and Wells found that the deprivation of this substance was
followed by profound changes in the pulp and dentine of guinea-pigs' teeth [2].

There is some hope that in the near future it will be possible to make
direct observations not only on the relation of diet to the development of teeth
but also to the production of dental caries. American workers have repeated
and extended some of my early experiments and claim to have produced caries¬
like lesions in rats' teeth by feeding these animals on diets deficient in
vitamin A, calcium, phosphorus, and other substances. If this hope is
justified a great advance will have been made in the study of dental defects,
for, although the experiments on the production of artificial caries in vitro are
of interest, observations of this nature do not appear to touch the real
problem. This type of work has resulted in almost universal concentration of
dental authorities on carbohydrates, and while I am prepared to admit that
these substances probably play a part in the development of dental caries, I
have failed to produce this condition in dogs even after feeding them for over
two years on a pappy diet containing on the average two ounces of glucose a
day ; nor has Howe [3] been successful in producing caries in guinea-pigs on
diets containing different carbohydrates.

It seems probable that the influence of carbohydrates on caries is not only
due to changes in the mouth but also to their action after digestion and
absorption. I have found that, under some conditions, foodstuffs, rich in
carbohydrates, such as cereals, antagonize the calcification of teeth. Their
action on caries may be closely related to this.

In order to get at closer grips with the problem of dental caries I have extended
my investigations to children. In a recent publication [lc] I pointed out that,
contrary to the usual teaching, a large number of children's deciduous teeth are
imperfect in structure. Out of 302 examined microscopically 84'5 per cent,
were badly formed. This percentage is to be contrasted with the 3 per cent,
described as hypoplastic by the dental surgeons who supplied the cases.
Thus it appears that naked-eye examination is, according to standards used
at present, of limited value in determining the structure of teeth. In the

Section of Odontology

following table the result of the histological examination of these teeth as
regards both structure and caries are set out:—

Table I.

Type No. examined

Incisors ... 47

Canines ... 29

First molars ... 88

Second molars... 138

302

Normal Structurk

No caries

Caries

—

Hypoplastic Structure

No caries

Carles

—

137

242

There is obviously a close relationship between structure and caries, since
838 per cent, of the teeth referred to were carious and 84*5 were hypo¬
plastic, but more detailed examination revealed that the correlation is not
quite so close as these figures imply, for eleven teeth were well formed and yet
carious, while thirteen were free from caries although defectively formed.
That is to say, of the 302 teeth examined twenty-four (7*8 per cent.) were
quite out of harmony with the hypothesis that well formed teeth are more
resistant to caries than those badly formed, whereas 278 (92*2 per cent.)
agreed with this hypothesis. Most of the exceptions were found in incisors
and canines. Thus, out of twenty-nine canines twelve were defectively
formed and yet free from caries, and five out of forty-seven incisors showed
some caries, in spite of being normal in structure. In the case of the
molars the correlation between structure and caries was almost perfect, for
only two out of 226 molars were quite free from caries and of these two the
first was well formed and the second had nearly normal enamel and dentine.

In trying to find a reason for the above-mentioned twenty-four exceptions
I was impressed by the varying types of secondary or adventitious dentine
found in many of the sections (see figs.). Throughout life the tooth has the
power of reacting to external stimuli whether these be of a physical or of a
chemical nature. For instance, even as the result of attrition of the enamel,
the pulp can apparently be stimulated to bring about alterations in the
primary dentine and also to form secondary dentine (see fig. 1). Caries
may cause a similar reaction.

Since the structure of the primary dentine is regulated by the quality of
the nutriment supplied during the actual growth and calcification of the tooth,
it seemed most probable that the same control might also operate in the
production of the secondary dentine. If this were the case, it would afford
an opportunity of testing the truth of the suggestion I had previously put
forward to explain the exceptions to the simple relationship between dental
structure and caries. I have elsewhere [ lc] suggested that:—

(1) If the nutrition of the child were “ good ” in early life but “ defective ”
after the eruption of the teeth, then the teeth would be well formed and there¬
fore, to some extent, resistant to caries, but less resistant than they would be
if the diet remained “ good ” throughout the whole period, for the resisting
power of the pulp, surrounding tissues, and saliva would be depressed.

(2) If the nutrition were ‘defective*’ in early life but “ good” afterwards,
then the imperfectly formed teeth would have their resistance to invasion
increased by the improved diet after eruption, but would again be more liable
to caries than when the diet was “ good ** throughout.

If the secondary dentine were badly formed under the first of the above

78 Mellanby: Effect of Diet on Resistance of Teeth to Caries

conditions and well formed under the second, then substantial support would
be given to the hypothesis that, apart from original structure, diet after
absorption plays an important part in regulating the resistance of teeth to
caries. I shall refer to this as the subsidiary hypothesis, the main hypothesis
being that well formed teeth are more resistant to caries and vice versa.

I shall now deal briefly with some evidence obtained in experimental
animals which tends to show that this subsidiary hypothesis is valid. Up to
the present time I have examined histologically the deciduous teeth of
about 100 puppies and found secondary dentine in only thirteen cases.
The relatively few cases in which secondary dentine is present in these
deciduous teeth can be easily understood, for the two main stimuli, attrition
and caries, responsible for its production in the teeth of man, are usually
lacking in the puppy experiments. The softness of the diet, no doubt, accounts
for the small amount of attrition in the puppies' teeth. I have begun
experiments to investigate this point further, and hope by artificial means
to induce more frequently the development of secondary dentine.

Microscopic examination showed the structure in these cases to be as
follows:—

Table II.— Secondary Dentine in the Teeth of Experimental Animals.

Well formed Badly formed

“Good” diet ... ... ... ... ... 7 ... ... 2

“ Defective” diet ... ... ... ... ... 1 ... ... 8

On the whole it would appear that the structure of the secondary dentine is
related to the type of diet eaten during the period of its formation (photo¬
micrographs illustrative of these facts can be seen in figs. 2 and 3). The
evidence on this point is meagre, and the problem demands further attention.

Table III gives a classification of the secondary dentine in the human
deciduous teeth previously examined for general structure. As explained
elsewhere, these teeth were first examined microscopically, and then ground
sections were made by Weil’s process.

Table III .—Type of Secondary Dentine in the 302 Human Deciduous Teeth.

Secondary dentine
Badly formed
Well formed
None

Good Primary Dentine Badly-formed Primary Dentine
and Enamel and Enamel

Caries (11)

No caries (30)

Caries (242)

No caries (13)

130

The exceptions to the general rule that structure and caries are closely
related consist of eleven teeth which are carious and yet are well formed (first
column), and thirteen teeth without caries although badly formed (fourth
column). In the first group, however, eight out of the eleven have badly formed
secondary dentine (fig. 5), in one case the pulp is replaced by cement, while
the remaining two show no evidence of reaction. In the other group of
exceptions, nine out of the thirteen have well formed secondary dentine (fig. 4).
The majority of the 302 teeth examined were carious, and had defectively formed
primary and secondary dentine (fig. 7). Thus it would appear that badly
formed secondary dentine is an indication of lowered resistance to caries even
when the enamel and primary dentine are good, and well formed secondary

Section of Odontology

dentine is an indication of increased resistance to caries even when the enamel
and primary dentine are badly formed. Thus twenty out of the twenty-four
exceptions to the general rule fall into line with the subsidiary hypothesis.
A definite proof of this subsidiary hypothesis, in support of which I have
supplied some evidence, would be of great importance, for it would suggest
a means different from any previously suspected of altering the resistance of
erupted teeth to harmful influences.

Further evidence which supports the hypothesis is seen in cases of teeth
where caries has been arrested. This process is a reaction controlled by the
activity of the pulp, and only takes place when this tissue is alive. The
extensive translucent zone in the primary dentine and the large amount of
secondary dentine often found in arrested caries, are evidences of the potent
reaction of the tooth, and are strongly suggestive of the unity of the problem
of arrested caries with that described above. It appears, in fact, that the
mechanism of dental defence controlled from the pulp and the inside of the
tooth is of great importance, and demands consideration in any study of the
aetiology of dental caries.

I have attempted to show that the reaction on the part of the tooth, both
to oaries and attrition, may be strong or weak, as evidenced by the amount
and condition of the secondary dentine produced during the reaction. Thus if
the secondary dentine is well formed, the damage produced by caries is
more likely to be slow or arrested than when it is poorly formed. I havo
provided statistical evidence which suggests that this holds in the case of the
deciduous teeth of children. The few results so far obtained in regard to-
the relation of diet to the structure of secondary dentine in animals indicate
that this relationship is similar to that already shown to exist between diet and
the structure of enamel and primary dentine.

If this should ultimately prove to be the case it will be evident that not
only is the structure of teeth controlled by the diet during their development,
but also that their subsequent resistance to caries and other harmful influences
is dependent on the food, and more especially on certain substances supplied to-
the body in some foods acting on the teeth by way of the blood-stream, through
the pulp, and possibly also in other ways. In other words, those dietetic^
conditions which result in the formation of perfect teeth, regularly arranged in
well-grown jaws, will also assist in the defence, even of badly formed teeth,
against noxious agencies.

Summary.

There is evidence that those dietetic conditions which, as I have shown in
earlier publications [l], control the formation of good enamel and primary
dentine, also confer upon teeth after eruption the power to resist bacterial
invasion and other destructive influences for :—

(1) The experimental evidence at present .existing, although small in-
amount, suggests that the pulp of erupted teeth reacts to destructive
stimuli, so as to produce well formed secondary dentine when the diet is
“ good,” and either does not react at all or only with the production of
imperfectly formed dentine when the diet is “ defective.”

(2) Among the children’s deciduous teeth examined, those which had
resisted caries, in spite of defective structure, show in general well formed
secondary dentine produced as the result of attrition (fig. 4), whereas those
which are carious but of normal structure have usually badly formed secondary
dentine (fig. 5).

80 Mellanby: Effect of Diet on Resistance of Teeth to Caries

(3) Diets which bring about the development of normal teeth in puppies
.are just those which enable the animal to resist bacterial infection. This
point has been mentioned in earlier publications.

Of course I would be the first to admit that what I have said to-night is
only part of the story, and that much more information is needed before
•dental caries can be really understood. On the other hand, the point of
view as illustrated by the experimental results described is, I think,
important, and will certainly lead to much further information concerning
the physiology and pathology of teeth and the related tissues.

The expenses of this investigation were defrayed by a grant from the
Medical Research Council, to whom my thanks are due.

REFERENCES.

[1] Mellanby, May, (a) Lancet , 1918, ii, p. 767 ; ( b ) Dental Record , 1920, xl, p. 65 ; (c) British
Dental Journal , 1923. [2] Zilva, S. S., ana Wells, F. M., Proc. Roy. Soc., 1919, B. 90, p. 505.

T3] Howe, Percy R., Dental Cosmos , 1920, lxii, p. 921. [4] Grieves, C. J., McCollum, E. V.,

.Simmonds, N., and Kinney, E. M., Bulletin Johns Hopkins Hospitaly No. 382, 1922, p. 202.

Fig. 1.

3?io. 1. —Human deciduous molar. Slight attrition of enamel at A, resulting in
changes in primary dentine B, and the production of secondary dentine at C.

Section of Odontology

Fig. 2.

Fig. 8.

Fig. 2.—Deciduous tooth of puppy showing a large amount of attrition of enamel
and dentine A, resulting in changes in the primary dentine B, and production of
secondary dentine C. Secondary dentine well formed as result of a “ good ” diet
after eruption and during time of attrition (cod-liver oil in diet).

Fig. 3.—Deciduous tooth of puppy showing secondary dentine C, associated with
attrition (not indicated in photomicrograph). Secondary dentine badly formed and
containing many interglobular spaces as result of “defective” diet after eruption
(olive oil in diet).

Fig. 4.

FlO- 4.—Human deciduous canine containing well formed secondary dentine C.
There is no caries although the enamel and primary dentine D are imperfect.

Fig. 5. Fig. 6.

Fig. 5.—Human deciduous incisor showing badly formed secondary dentine C,
with many interglobular spaces. The tooth is carious although the enamel and
primary dentine D are well formed.

Fig. 6. —Human deciduous incisor (Mr. Law’s case) showing pulp filled with
cement K. The tooth is carious although the enamel and primary dentine are well
formed.

Fig. 7.

Fig. 7.—Human deciduous molar showing badly formed primary dentine D, and badly
formed secondary dentine C. Tooth carious.

PROCEEDINGS

OP THE

EOTAL SOCIETY OF MEDICINE

EDITED BY

Sir JOHN Y. W. MacALISTER

UNDER THE DIRECTION OF

THE EDITORIAL COMMITTEE

VOLUME THE SIXTEENTH

SESSION 1922-23

SECTION OF OPHTHALMOLOGY

LONDON

LONGMANS. GREEN & CO.. PATERNOSTER ROW

1923

Section of ©pbtbalmoloo?

OFFICERS FOR THE SESSION 1922-23.

President —

A. L. Whitehead, M.B., B.S.

Vice-Presidents —

W. T. Holmes Spicer, F.R.C.S.
J. Herbert Fisher, F.R.C.S.
Sir William Lister, K.C.M.G.,
F.R.C.S.

Sir John H. Parsons, C.B.E.,
.R.C.S., F.R.S.

C. H. Usher, F.R.C.S.Ed.
James Taylor, C.B.E., M.D.
Bernard Cridland, F.R.C.S.Ed.
J. Gray Cleog, F.R.C.S.

Hon. Secretaries —

R. Affleck Greeves, F.R.C.S. Montague L. Hine, M.D.

Other Members of Council —

S. A. K. Wilson, M.D.

T. Grainger Stewart, M.D.

S. H. Browning.

Sir Richard R. Cruise, K.C.V.O.,
F.R.C.S.

F. A. Juler, F.R.C.S.

G. W. Thompson, F.R.C.S.

Malcolm L. Hepburn, F.R.C.S.

R. R. James, F.R.C.S.

M. S. Mayou, F.R.C.S.

Ransom Pickard,

W. H. McMullen, O.B.E.,
F.R.C.S.

A. Levy, M.D.

C. B. Goulden, O.B.E., F.B.C.S.

D. Leighton Davies, M.S.

T. Harrison Butler, M.D.
Lieut.-Colonel H. HERBERT,

F.R.C.S., I.M.S.

C. Killick, F.R.C.S.

E. H. E. Stack, F.R.C.S.

C.B., C.M.G., M.S.

Representative on Library Committee (Honorary Librarian of the

Bowman Library )—

R. R. James, F.R.C.S.

Representative on Editorial Committee —
R. Affleck Greeves, F.R.C.S.

SECTION OF OPHTHALMOLOGY

CONTENTS.

October 13, 1922.

Raynkr Batten, M.D. page

Calcareous Degeneration of the Eye, with Deposits on the Iris ... 1

F. A. Williamson-Noble, F.R.C.S.

A Plane Glass Retinoscope ... ... ... ... .. 1

A. L. Whitehead, M.B. (President).

Some Aspects o Ocular Tuberculosis ... ... ... ... 2

N. Bishop Harman, F.R.C.S.

Standards of Vision for Scholars and Teachers in Council Schools

(Abstract) ... ... ... ... ... ... ... 7

November 10, 1922.

Humphrey Nbame, F.R.C.S.

A Case of Retinitis Circinata ... ... ... ... ... 11

Montague L. Hinb, M.D.

Case of Ectopia Lentis (both Eyes)... ... ... ... ... 12

Leslie Paton, F.R.C.S.

(1) Hsemangeioma of Orbit ... ... ... ... ... 18

(2) Case of Recurrent Detached Retina after Seventeen Years’ Reposition 14
R, Affleck Grbevbs, F.R.C.S.

Case of Bilateral Proptosis, with Limitation of Movement in One Eye ... 15

J. F. Cunningham, F.R.C.S.

Tumour of Right Upper Lid (Angeioma) ... ... ... ... 15

M. W. B. Oliver, M.B.

Plastic Operation for Contracted Sockets ... ... ... ... 15

F. A. Juler, F.R.C.S.

Case of Retinal Degeneration, with Mental Deficiency ... ... 16

January 12, 1923.

J. A. Valentine, M.D.

Night Blindness : Retinitis Pigmentosa sine Pigmento ... ... 17

Contents

A. H. Levy, M.D.

Case of Amaurotic Family Idiocy ...

Montague L. Hine, M.D.

Two Cases of Early Familial Maculo-cerebral Degeneration .
Percy Bardslky, M.B.

Case for Diagnosis (? Polycythsemia Rubra) ...

R. Lindsay Rea, M.D., F.R.C.S.

Case of Hole in the Hyaloid

T. Harrison Butler, M.D.

Some Unusual Results of Operations for Cataract
Charles Killick, M.D.

The Treatment of Conical Cornea (Abstract)

February 9, 1923.

Leslie Paton, F.R.C.S.

Optic Atrophy after Herpes Ophthalmicus ...

Rosa Ford, M.B.

Intracranial Tumour causing Quadrantic Hemiopia ...

M. S. Mayou, F.R.C.S.

Case of Subhyaloid Haemorrhage in a Girl

A. C. Hudson, F.R.C.S.

Two Cases of Primary Band shaped Opacity of both Corneae .
F. A. Williamson-Noble, F.R.C.S.

Atrophic Patches at the Macula Tuberculous ; ? Cyst

March 9, 1923.

Humphrey Neamk, F.R.C.S.

Tumours of Optic Nerve ...

F. A. Williamson-Noble, F.R.C.S.

Endothelioma of the Orbit (Abstract)

June 8, 1923.

H. M. Joseph, M.C., M.B.

Case of Progressive Macular Changes associated with Tremors
Montague L. Hine, M.D.

Familial Nodular and Reticular Keratitis

Shown by Ida C. Mann, M.B., B.S.

Some Suggestions on the Embryology of Congenital Crescents

Philip Doynb, F.R.C.S.

The Tournay Reaction (Abstract)

Contents

SECTIONS OF MEDICINE AND OPHTHALMOLOGY.

(JOINT MEETING.)

November 28, 1932.

DISCUSSION ON “THE SIGNIFICANCE OF THE VASCULAK AND
OTHER CHANGES IN THE RETINA IN ARTERIO SCLEROSIS
AND RENAL DISEASE.”

Dr. G. Newton Pitt (Chairman) (p. 1), Dr. H. Batty Shaw (p. 1), Mr. R. Foster
Moore (p. 5), Mr. Percy Bardslky (Salisbury) (p. 15), Mr. Philip Adams
1 Oxford) (p. 16), Dr. Arthur Ellis <p. 17), Dr. C. 0. Hawthorne (p. 20), Dr.
•J. F. Gaskkll (Cambridge) (p. 20).

December 8, 1922.

ADJOURNED DISCUSSION ON “THE SIGNIFICANCE OF THE VAS¬
CULAR AND OTHER CHANGES IN THE RETINA IN ARTERIO¬
SCLEROSIS AND RENAL DISEASE.”

Mr. Ernest Clarkk (p. 22), Dr. W. N. Goldschmidt (p. 28), Mr. D. Leighton
Davies (Cardiff) (p. 26), Mr. M. S. Mayou (p. 27), Dr. G. Newton Pitt
(Prevident of the Section of Medicine) (p. 28), Dr. A. Feiling (p. 29), Mr. J.
Herbert Fisher (p. 80), Dr. C. F. Harford (p. 82), Dr. Batty Shaw (in reply)
(read by Dr. Izod Bennett) (p. 38), Mr. R. Foster Moore (in reply) (p. 35).

The Society does not hold itself in any way responsible for the statements made or
the views put forward in the various papers.

orn - 2

London:

John Balk, Sons and Danielsson, Ltd.,

Oxford House,

83-91, Great Titchfield Street, Oxford Street, W. 1.

Section of ®phtbalmolod\>.

President—Mr. A. L. Whitehead, M.B.

Calcareous Degeneration of the Eye, with Deposits on

the Iris.

By Rayner Batten, M.D.

PATIENT, a male, aged 71. History of injury to right eye when aged
2 years. Corneal opacity: dense, white, opaque, and apparently crystalline.
Bright white deposits on the pupillary margin of the iris.

The following cases were also shown :—

(1) “Cyst of the Retina,” By J. A. VALENTINE, M.D.

Discussed by Mr. Treacher Collins.

(2) “Angeoid Streaks of the Retina.” By F. A. Williamson-Noble,

F.R.C.S.

A Plane Glass Retinoscope.

By F. A. Williamson-Noble, F.R.C.S.

This consists of two metal tubes set at an angle of 30°. At the end of
one tube is mounted a 30 c.p. “pointolite ” in a light-tight casing, with a lens
and focussing arrangement so that a beam of parallel rays is projected down
the centre of the tube. Adjustable stops are provided in front of and behind
the lens and an orange-red colour filter is fitted. At the end of the second
tube is an automatic lens-changing mechanism. Where the tubes are joined
there is a piece of plane glass, so arranged that it projects a reflected beam of
light towards the lens-changing mechanism.

The surgeon sits about a foot away from the plane glass, the patient at the
end of the tube carrying the lens-changing mechanism ; he is directed to look
at the image of the source of light formed by the plane glass. The surgeon
will see the usual yellow-red reflex from the patient’s fundus, and on moving
his head will note that the “ shadow ” moves with him in hypermetropia and
myopia of less than lD. and against in myopia exceeding Id.

By turning the handle of the lens-changing mechanism, neutralization is
effected in the two meridians.

The instrument shown was the experimental model, the final form will be
slightly different and will incorporate some improvement. It was designed
with the following objects in view :—

(1) To enable one to perform retinoscopy at the macula without the use of
a mydriatic.

(2) To cut out all light from the surgeon’s eye except what is reflected
from the patient’s fundus.

(3) By means of the stops and colour filter to diminish the luminosity of
Ibe image at which the patient gazes to a point where it produces no
unpleasant dazzling.

(4) To enable one to make lens-changes with great speed and in practically
total darkness.

Ja~0p i

[October 13, 1922.

Whitehead: Some Aspects of Ocular Tuberculosis

Some Aspects of Ocular Tuberculosis:

PRESIDENT’S ADDRESS.

By A. L. Whitehead, M.B. (President).

The tubercle bacillus is so widely distributed and lesions due to it are so
common elsewhere in the body that it is only natural that much should have
been written about tuberculous diseases of the eye. I do not propose to occupy
your time with a digest of the extensive literature on the subject, but to give
you some of my own impressions of ocular tuberculosis, in comparison with
the experience of other observers.

Tuberculosis is more frequent in Leeds and less frequent in the West Riding
of Yorkshire than in England and Wales as a whole. The official figures
supplied to me by the Ministry of Health and the medical officer's annual
reports are as follows for 1920 : England and Wales, with a population of
37,524,000, had a tuberculosis case-rate of 2*07, the lowest since 1914. The
West Riding of Yorkshire, with a population of 1,498,453, had a case-rate of
1*61, also the lowest since 1914. Leeds, with a population of 448,913, had a
case rate of 2*61, the lowest since 1914.

A large percentage of our patients in hospital and private practice
reside outside Leeds, so that probably on the average the general case-rate
will not be very dissimilar to that of England and Wales as a whole.

Every ophthalmologist must have been struck by the comparative rarity
of tubercular lesions of the eye in pulmonary tuberculosis, and in serious
cases of surgical tuberculosis, but if cases of ocular tuberculosis are fol¬
lowed up, there is good evidence that in after years other manifestations are
frequently present.

A valuable paper bearing upon this point was contributed in 1921 by
Igersheimer and Prinz [l], dealing with the after-history of ninety-two
scrofulous eye cases followed up for ten to thirty years. The authors found
that in 13*9 percent, there were changes in the lungs, and in 13 per cent,
there were symptoms of active tuberculosis. In discussing the various forms
of ocular tuberculosis, I shall refer again to this question.

There seems to be a very important difference between the severe spreading
invasions of the eye, leading to more or less complete destruction of the eye¬
ball, and the more chronic and benign forms of tuberculous infiltration. In the
former, typical giant cells are common, and the tubercle bacilli are frequently
found ; in the latter, careful search and inoculation tests usually fail to
demonstrate the bacillus. There is a general consensus of opinion that in the
latter group of cases the infection is due to a tuberculotoxin acting on a
specially prepared area. This view has been supported by experimental
evidence furnished by Guillery [2] and others.

I do not propose to say anything about conglomerate tubercle of the uveal
tract, leading to destruction of the eyeball, either by perforation of the outer
coats of the eye or by caseatipn and subsequent shrinking of the globe. The
recognized text-books deal very fully with this condition, and my experience
coincides with the usual description.

Tubercular Choroiditis .

Miliary tubercles of the choroid in acute tuberculosis of infants are fre¬
quently present. In nearly all of the many cases of fatal tubercular menin-

Section of Ophthalmology

gifcis in which I have had the opportunity of examining the fundus, I have
found miliary tubercles. Isolated tubercles, usually single, are not infrequent,
and, unless at or near the macula, attract little attention. They occur in the
same class of individuals in whom these less severe forms of tuberculous
infection of the eye are usually found. They are small, one-third to one-half
of the size of the optic disc, greyish yellow with a soft indefinite margin. In
the later stages the circular clean cut edges of the atrophic patch are very
characteristic. Occurring in early infancy, they are not usually recog¬
nized until, as the child grows up, the interference with vision attracts
attention. I do not think I have seen them in individuals over the age
of 30.

Primary Tubercle of the Retina .

I have not seen a case of primary tubercle of the retina, but I have notes
of one case in which I regarded a nodule in the papilla as probably
tubercular.

Degenerative changes in the blood-vessels, usually the veins, followed by
haemorrhages, either small, confined to the retina, or large, bursting into the
vitreous, have been described by Jackson and Finnoff and by de Schweinitz.
In my own experience, in two instances, vitreous haemorrhages have preceded
any other manifestations of general tubercular infection. In both these cases,
pulmonary tuberculosis became manifest in from twelve to eighteen months
after the appearance of the haemorrhages; in one a typical tubercular iritis
with nodules came on after the pulmonary signs were defined, but cleared up
under treatment.

Chatterton [3], at a meeting of this Section in 1913, reported a case of
tubercular iritis with vitreous haemorrhages treated by tuberculin. It is
possible that some of the unexplained cases of recurrent vitreous haemorrhage
may be due to toxin infection from a tubercular focus elsewhere in the body.
Several observers, notably Schieck [4], have reported favourably on the use of

tuberculin in recurrent retinal haemorrhages.

Tubercular Iritis .

I have nothing to add to the text-book descriptions of the various forms of
tubercular nodules in the iris. We have all seen many examples of the recog¬
nized varieties. Here I would point out that in many of the milder cases
the nodules are small, disappear early, and leave little, if any, permanent
change in the iris structure. They usually occur in young and apparently
robust young adults, frequently females, and with no other evidence of tuber¬
culosis, but often with the family history of susceptibility to infection. In
these cases the value of tuberculin treatment by proper dosage has been
repeatedly demonstrated.

Hessberg [5] considers that more than 50 per cent, of all cases of iritis
are attributable to tuberculosis; he states that the nodules are frequently very
small, lasting often only a few hours, and may disappear without leaving
any scar. Phthisis and joint tuberculosis are rarely present, but the
lymphatic glands of the mediastinum and mesentery are frequently affected.
I do not think many ophthalmologists will agree with this extraordinarily high
percentage.

Tuberculoid Disease of the Lacrymal Sac.

Tuberculous disease of the lacrymal sac is not common in my experience.
I have seen it secondary to lupus of the nose, and as a forward extension of
tubercular disease of the ethmoid.

4 Whitehead: Some Aspects of Ocular Tuberculosis

The possibility of the occurrence of a an epiphora and dilatation of the sac
secondary to nasal tuberculosis should always be remembered in young adults.
In one case under my care, such a chronic dacryocystitis followed a tuber¬
culous ulceration of the inferior turbinate and septum. Tuberculous ulceration
of the vulva occurred in this case—that of a girl, aged 12, and it was entirely
cured by local and general treatment; but a year later a toe had to be ampu¬
tated for tubercular “ dactylitis ” ; then the nose and lacyrmal sac became
affected. Later on the pharynx and larynx were involved. The whole process
has continued for five years, and during that time the child has looked the
picture of health, and is of the most robust physical development. What her
ultimate fate will be I cannot say.

Tubercular Conjunctivitis .

The severe forms of tubercular conjunctivitis with large subepithelial
nodules leading to ulceration and formation of large granulations and the
so-called coxcomb excrescences are rare in my experience. Lupus of the
conjunctiva spreading by direct infection from the face is quite characteristic
and calls for no comment.

Many papers have been written in many languages discussing the possible
tuberculous origin of the common phlyctenular conjunctivitis of children.
Veeder and Hempelmann [6], in the New York Medical Journal of 1920,
reported 196 cases of phlyctenular disease. There was a positive von Pirquet
skin reaction in ninety-three cases. Tuberculous lesions involving other
organs were found in half the cases, and in children kept under observation
for one year or longer four-fifths gave evidence of other tuberculous processes.

For some time past I have frequently noticed a type of phlyctenular
conjunctivitis which I have come to regard as definitely tubercular. It occurs
in young adults, rarely in small children, is very chronic in type and is
resistant to the ordinary treatment. The phlyctenules are small, closely set,
aggregated together near the corneo-scleral junction and there is frequently
infiltration of the cornea, with rather large invading vessels ; ulceration is very
rare. In some instances iritis is also present. I have water-colour drawings
of two typical cases of this variety of conjunctivitis with slight corneal
invasions and iritis.

In all the cases there are either evidences of tuberculous processes elsewhere
or a clear family history of susceptibility to tubercle invasion. The von Pirquet
reaction is frequently positive, but not invariably so, although a definite but
slight reaction occurring between twenty-four and forty-eight hours after
inoculation, and regarded by some observers as positive, is almost always
present. Examination of the tissue removed does not show typical giant cells
or the presence of tubercle bacilli, and inoculation of guinea-pigs has given
negative results.

Although this group of cases is very resistant to ordinary treatment,
immediate and striking improvement follows tuberculin injections. It is most
important to give in each case the appropriate dose. Tuberculin B.E. is used
and the initial dose is 1/5,000 mg. to 1/10,000 mg. according to the age of the
patient; four-hourly temperature records are taken for twenty-four hours with
the patient in bed ; if there is no temperature or general reaction, an increasing
dose is given three days later. Our usual scale is 1/5,000, 1/2,500, 1/1,000,
1/750, 1/500, 1/250, 1/100, 1/50 mg. When the reaction is obtained the dose
is repeated and if there is again a reaction, the dose just smaller than the
earlier one is given, and repeated at weekly or fortnightly intervals according

Section of Ophthalmology

to the case. I have dealt with this in detail, since I am quite satisfied
that only the dose suitable for the individual will give good results. The
efficient dose has varied from 1/50 mg. to 1/500 mg. f even in cases of about
the same age, this showing the uselessness of a uniform dose. A severe
general reaction is very unusual, an elevation of temperature of 1° to 2° being
the usual indication ; in a very few cases local reaction with suppuration at the
site of injection is the only indication.

I have no experience of the method suggested by Ellis and Gay [7] of
treating tuberculous eyes by the direct local application of various dilutions
of tuberculin P.T.O. (bovine), and I do not know whether the authors have
found that a more prolonged trial of this treatment justifies its use.

Appropriate constitutional treatment is essential; if possible an entirely
open-air life on sanatorium principles should be insisted upon.

Since it is an almost established fact that these minor lesions of ocular
tuberculosis are due to toxin infection from a focus elsewhere, it is most
important to search for such a focus and when it is found, to employ suitable
treatment. Infected tonsils and adenoids should, of course, be dealt with by
operation.

The question of treatment of enlarged glands by operation or otherwise
is also of great importance. Wolff [8], of Amsterdam, has strongly urged the
value of the treatment of the tuberculous lymphatic glands by X-rays in cases
of tubercular conjunctivitis and keratitis. I have no experience of this, neither
have I tried injections of milk in these cases. After an X-ray examination of
the thorax in cases of chronic uveitis, Siegrist [9] came to the conclusion
that the intrathoracic bronchial glands were probably the primary focus.

Professor Stewart has supplied me with some very important observations
directly bearing upon the question of the possibility of the mediastinal glands
being the primary focus in cases of toxin infection of the eye.

In post-mortems in 100 cases of death from rapidly fatal war injuries in
men of the best physique, from the front lines, the following striking facts
were elicited. In 42 per cent, there were undoubted evidences of tuberculous
disease, in 11 per cent, scarring at the apices of the lungs and in 1 per cent,
extensive old pleuritic adhesions, making 54 per cent, probably tuberculous
lesions. In 32 per cent, of the cases there were definite signs of glandular
infection, 15 per cent, being bronchial, 15 per cent, mesenteric, 1 per cent,
pre-pancreatic, and 1 per cent, cervical.

In view of these facts indicating the frequency of latent tuberculosis in
the glands, it seems very probable that the primary focus in these cases
of tuberculo-toxin infection may be in the bronchial or other glands.
Kleinschmidt [10] believes that only a small portion of phlyctenular cases
are free from tubercle while many others have merely a quiescent lesion.

Ordinary local treatment is usually employed, atropin ointment and boric
acid lotion irrigations in the early stages, yellow oxide of mercury ointment
and powdered calomel insufflations as the more acute symptoms subside.

Operative treatment in some of the cases is of the greatest value. I have
tried excision of the affected conjunctiva in some cases, but without especially
satisfactory results. In cases in which there is a vascular invasion of the
cornea, a form of peritomy is of very great service.

The most satisfactory results seemed to be obtained if a strip of conjunctiva,
2 or 3 mm. in width is excised all round the corneo-scleral junction and the
larger superficial vessels involving the cornea are carefully scarified by the point
of a Graefe’s knife ; six or seven cuts are made across each vessel.

Whitehead: Some Aspects of Ocular Tuberculosis

The value of peritomy has been emphasized by several ophthalmic
surgeons ; my revered colleague, Mr. Pridgin Teale, possibly the doyen of
ophthalmologists, has advocated the operation repeatedly, and in later years
Sir Anderson Critchett and Sir Richard Cruise have urged its performance in
suitable cases. Personally I am firmly convinced that it is one of the most
valuable aids which we possess in the treatment of these otherwise very
intractable cases.

In ten recent cases of the type of phlyctenular conjunctivitis which I have
described, the ages ranged from 10 to 27, the average being 15’3. In four cases
there were enlarged cervical glands ; in one a patch of lupus on the cheek, not
in the neighbourhood of the eye ; in one a tubercular synovitis of the knee;
in one the mother had suffered from tubercular peritonitis and in another
a sister died of acute pulmonary tuberculosis. Many of the cases had been
under the usual treatment for long periods without benefit; in one case for
nearly three years and in another for over eighteen months. Peritomy waa
performed in five cases. In one case in which vision had been less than six
months ago, it is now JJ- in one eye and partial # in the other and the corneal
opacities have almost disappeared. In all, the improvement was rapid and
very marked, and there has been an entire freedom from relapses, which had
been frequent before the special treatment was undertaken.

Tubercular Keratitis .

Tubercular keratitis following infection after injury is, I think, rare, and
secondary infection from the conjunctiva, the ciliary body or the iris is equally
uncommon. A parenchymatous affection, to some extent simulating the
keratitis of congenital syphilis, is frequent and is worthy of greater attention.
In tubercular keratitis, the surface of the cornea is more irregular; although
actual ulceration is rare, the patches of opacity are less regular in distribution
and the vascular invasion of the cornea is much more superficial. The onset
is not so rapid and the progress is much more erratic. In congenital syphilis
it is usual to find the keratitis steadily and progressively advancing, followed
by steady and progressive resolution. Peritomy is, in my experience, of the
greatest value in the treatment of the pannus of tubercular keratitis and quite
valueless in congenital syphilitic keratitis. The possibility of a mixed infection
must always be borne in mind.

Tubercular Scleritis.

Tubercular scleritis and episcleritis, often with involvement of the iris and
cornea, are possibly in some instances due to direct tuberculous infection. One
of the most serious and intractable cases I have ever seen, occurred in a
gentleman whose wife was suffering from advanced pulmonary tuberculosis;
although he himself had no evidence of infection elsewhere.

The conclusions to which my observations point, but for which I do not
claim any originality, are these:—

(1) Ocular tuberculosis is much more frequent than is usually taught.

(2) Two very well defined classes of lesions exist: (a) The destructive,
caseating or necrosing variety in which the infection is primary, or part of a
generalized distribution of tubercle, progressive, and only slightly, or not at
all, amenable to treatment. Tubercle bacilli are frequently discovered in these
cases, (b) A much milder form of infection, often called attenuated tuber¬
culosis, probably of atoxic nature, since bacilli and giant cells are rarely found.
The primary focus is usually not in the eye, and in many cases cannot be

Section of Ophthalmology

discovered by a careful investigation. The bronchial or mediastinal glands
may in many instances be the focus in question.

In the second class recovery is the rule, with more or less interference
with vision according to the areas of the eye affected. In the treatment of
this group, properly graduated tuberculin injections are of the greatest value.
In tubercular vascular keratitis, peritomy and scarification of the invading
vessels is a most valuable aid to treatment.

If the primary focus is in a situation where removal can be carried out by
surgical means, operation should be carefully considered.

If, as seems frequently the case, the focus is in the bronchial or mesenteric
glands, constitutional treatment of the most thorough variety obtainable must
be undertaken.

Finally, I wish to express my indebtedness to Professor Stewart and
Dr. McLeod, of the Pathological Department of the University of Leeds, for
valuable assistance in investigating the pathology and bacteriology of some of
my cases; to Mr. S. D. Lodge and the sisters of my wards in the General
Infirmary at Leeds, and to various tuberculosis officers, for the careful
supervision and execution of the treatment.

REFERENCES.

[1 Igersheimer and Prinz, Gracfe's Arch. f. Ophth 1920, cv. [21 G\ illery, Munch, med.
UWi., 1921, lxviii, p. 201. [3] Chatterton, Broc. Hoy. Soc. Med., 1913-14, vii (Sect. Ophth.),

p.5. A) SCH1KCK, Klin. Monntshl.f. Auyenheilk., 1920. lxv, p. 114. [5] Hessbkkg, Bert. klin.

IW., 1920, lvii, p. 11. [6] Veedkh and Hempelmann, New York Med. Joum., 1920, cxii,
P-1008. [7[ Ellis and Gay, Lancet , 1917, ii, p. 156. in; Wolff, Brit. Joum. Ophth., 1920,
iv, p. 53. T9j Siegrist, Rev. yen. d'Ophth. 1920, xxxiv, p. 280. [10j Kleinschmidt, Bcitr. z .

Kim. dtr Tuberkul., 1921, xlviii, p, 188.

Standards of Vision for Scholars and Teachers in
Council Schools.

(ABSTRACT.)

By N. Bishop Harman, F.R.C.S.

[This paper will shortly be published in full in the British Medical Journal.]

The teacher’s life is a hard one. Short hours and good holidays do not
ensure against risk of strain to normal eyes, and the risk is increased where
there is defect. The teacher’s work is not limited to the classroom, there is
much preparation to be done; also in schools worth the name there is a large
social element the organization of which falls to the teacher in State schools
and not to prefects and the like.

The State has provided an “ educational ladder ” : scholarships, college,
and university training. It is a corollary of this provision that there should
he required of the recipient of these bounties sufficient physique to take
advantage of them; otherwise there is waste, and better candidates may be
kept out by the failures. Tests of vision exist, but it is desirable that these
should be standardized; otherwise the anomaly arises that a teacher trained
! D one area is refused in another, whereas trained teachers should be freely
interchangeable, for free movement engenders breadth of view and experience.

Junior scholarships are awarded at the age of 11, and give five years at a
secondary school; senior scholarships are awarded at 16 years, and give four

8 Harman: Standards of Vision for Scholars and Teachers

years at a university ; the training college is entered at 16; and teachers are
admitted to their work at 21.

Evidence of the disability of defective vision was recently given by the
author so far as myopes are concerned. 1 It was found that myopes of 3 to 5D.
engaged in continuous close work showed failure to work to the extent of
33 per cent.; those from 5 to 10 d. to the extent of 60 per cent.; and those
over 10 d. to 77 per cent. The whole of these myopes showed a percentage of
failure of 53 per cent., whereas myopes of the same order who did not engage
in continuous close work only failed to the extent of 9’4 per cent.

On this basis standards have been worked out and are submitted for
consideration. Starting with the allowable margin of error in teachers at the
age of 21, the difference is estimated for the children at the age of 11. The
table as given embodies the following results:—

Table op Standards.

(a) Hypermetropia.

Candidate**

Age

Sphere

Cylinder

Sphero-cylinder

All

11-21 1 5d.

4D.

Average of four meridians - - 5; astigmatism not over
3 d., e.g., -f 3*5 d. sph. with -f 3 d. cyl.

(b) Myopia , with mixed Astigmatism .

Teach erships

Senior scholars

Junior scholars

5d.

4D.

3d.

4d.

3d.

Ditto ditto

Average of four meridians - 4; astigmatism not
over 3 d., e.g., - 3 d. sph. with - 2 d. cyl.

Average — 3 d,; astigmatism 2 d., e.g., - 2 d. sph.
with - 2d. cyl.

Allowance is made for a number of possible defects due to odd eyes, old
inflammations resulting in scarred eyes, and the like, amblyopia from squint,
and defects of colour vision.

Difficulty may sometimes arise in the disbarring of young myopes who are
alleged by their teachers to be “ brilliant/’ Too much stress should not be
laid on these reports. Myopes give an undue amount of time to close work
because the state of their sight is a handicap for games. This gives them an
unfair advantage over their normal comrades, who may be the better workers
in the long run. The 2d. difference between teacher and junior scholar in the
allowable degree of myopia is none too much for ten years’ hard study from
the age of 11 to 21—just the most critical years of development.

It is better in such cases, both in the interests of the candidates and of the
teaching service, to divert their work at an early age to safer channels. There
are now many “ trade scholarships,” the work of many of which entails little
strain on the eyes, and which provide an entry into valuable spheres of
usefulness. For some few whose capacities are clearly scholastic it is possible
to provide an avenue through training for teachers in schools for the blind
and in myope classes.

DISCUSSION.

Dr. F. C. Shrubsall said that the subject of myopia was of great importance,
and if tests broke down, the official to bear the brunt was the school medical officer.
When the school medical officer rejected a candidate, he was supposed to suggest
alternatives. He quoted the case of a girl, aged 13, who wished to commence work

1 Trails. Ophth . Soc , U.K. , 1922, xlii, pp. 20-25.

Section of Ophthalmology

for the teaching profession. As it was held that the profession was unsuited to her,
she was rejected. She then brought a certificate from the ophthalmic department of a
large hospital, in the following words : “ I see no objection to this girl having a scholar¬
ship provided she does not overdo near work, and she should not do any unnecessary
reading, such as novels, nor should she read at night.’ 1 He believed these limitations
were sure to be exceeded, whatever warnings were given, and the hours and conditions
of work could not be controlled from the school. And in recommending alternative occu¬
pations strange difficulties might arise. Cases of defective vision were often recom¬
mended for agriculture, but it was pointed out to the school medical officer that a boy
who could not see properly would hoe up the potatoes and leave the weeds behind. It
was said that school work was the cause of myopia, but there was little doubt that in
many cases myopia was inherited in families, and was manifested mostly by the female
members of it, not uncommonly being associated with a studious frame of mind, and such
a person could not be induced to abandon study for open spaces. Most of the figures
relating to myopia in school life had come from Swedish and German sources, and it
was shown that abroad myopia was diminishing. The results had been variously
assigned to the introduction of physical exercises and to the giving up of intense
classical studies and the use of Gothic print. But in this country the conditions of
study and home-work had never been so severe. Lighting arrangements had been
held accountable in assigning a cause for the prevalence of myopia, but a report from
Strasbourg, issued in 1912, stated that there was a greater incidence of myopia in
the light schools of the suburbs than in the darker schools in the centre of the whole
town. General hygiene must play a part, but most observers placed the greatest stress
on heredity. E. Thomson gave the proportion in different school populations in
Lancashire as: urban 17 per cent., rural 20’5 per cent., mining 26 per cent. The
school medical officer must come to the ophthalmologist for guidance, and it was
desirable that this should be authoritative and generally accepted. It was very
desirable that a committee of experts should consider the subject and issue some
standard.

Mr. Ernest CLARKE, after suggesting that the considered opinion of the Section
should be forwarded to the Council of British Ophthalmologists, said that when one
came to arrange the standards, the matter was very difficult if one had to confine oneself
to the eyes. He thought the physique of the child should be taken into account as
well. Again, the previous history was very important, especially in regard to myopia.
In a dozen cases of myopia ten might remain stationary, or would progress very
slightly, while in the other two no treatment would seem to stop the progress. He
supposed an allowance of 2d. for the progress up to the age of 21 might be taken as
the average. With regard to hypermetropia, he thought Mr. Harman was very liberal
in allowing 5d. Again, what about the astigmatism ? He thought it was the small
errors of astigmatism which counted much more than the big ones. He asked whether
Mr. Harman was wise in admitting the amblyope. The squint might be cured, but if
the eye remained amblyopic he or she remained a one-eyed person. If Mr. Harman
allowed that child to be a scholar, and afterwards to become a teacher, would he also
admit one who had lost his eye from an accident *? He agreed with the remarks con¬
cerning special exceptions. It was known that some people were bom teachers, and,
as far as possible, they should be encouraged to adopt teaching as their profession. It
seemed to him that what the standard should be was largely a question of supply and
demand. If there were plenty of scholars and plenty of candidates for teacherships,
a high standard could be set, but if there were a paucity of supply, the standard would
have to be lowered.

Mr. INGLIS POLLOCK said that the standard advocate*! by Mr. Harman had
already been assumed in Glasgow. If there were a bulging of the posterior segment,
or any sign of fundus disease, that disqualified the child, so did a visual acuity of
below J and myopia of over 4d. The children there passed into training at 15 or
16 years of age, when they were subjected to a medical examination, and the eyes
were examined independently by an oculist, who had not to do with the candidate’s
general health. The person responsible for their admission had to consider all the

10 Harman: Standards of Vision for Scholars and Teachers

factors. If satisfactory, the child proceeded to four years of training, at the end of
which period he had another medical examination. If at 18 years of age he was found
to be more myopic, he was disqualified. Inquiry was made as to whether there was
myopia in the family, and if so, and if the myopia in the child was on the increase,
rejection ensued, unless the candidate agreed to be excluded from the superannuation
scheme. It might be that after the four years the examiner was a different one from
the one who made the first examination. If a candidate was to be rejected, it was most
important that this should be decided upon before the four years of training were
entered into, as after 19 years of age it was too late for training for most trades. At 40
to 45 years of age, the myope might have stretching of the eyeball and atrophy of the
macula setting in, therefore one had to consider the exclusion of those who might
become partially blind.

Mr. T. Harrison Butler said that as teachers were paid by a public body it was
legitimate to lay down a standard of eyesight for them, but the matter of awarding
scholarships was on a different footing. He could not see that because a child had
myopia of 3d., which might or might not be progressive, he should not be allowed to
hold a scholarship, and denied a liberal education. Discretion must be allowed to the
medical man who was called upon to decide the fitness of the child. It was not possible
to settle the question from one examination. If the child was found to be myopic it
was necessary to examine it again after a year or more; then and then only could
it be said that the disease was progressive. A hard and fast standard would exclude
many clever children and condemn them to hand labour for which they were perhaps
unfitted. It would also be detrimental to the general standard of education, for the
myope was often highly studious and likely to profit from a scholarship. He believed
that there was no conclusive evidence that the progress of myopia was dependent upon
near work.

Mr. A. L. Whitehead (President) said that it occurred to him that Mr. Harman
had practically never considered the question of the visual acuity of the individual;
he merely dealt with the error of refraction in figures. He (the President) felt that
while the widest discretion should be allowed in individual cases, some sort of standard,
such as Mr. Bishop Harman suggested, would be of great value as forming a basis on
which to work.

Mr. BISHOP Harman (in reply) said that he assumed a reasonable visual acuity for
teachers ($ each eye, or $ the better eye when one was defective) ; but he would
strongly urge that visual acuity was not the main test for these purposes. Mr. Ernest
Clarke’s plea for a distinction between the robust and the puny was not the business
of the ophthalmologist, who had to deal with the eyes alone. Low degrees of
astigmatism were troublesome, but they could and should be corrected. He would
not object to a one-eyed teacher. It was possible to recognize Mr. Harrison Butler’s
suggestion that weight should be attached to the point as to whether or no the myopia
was progressive. The belief that myopia had nothing to do with close work he was
sure was wrong. He had referred to the histories of 480 myopes 1 classified according
to age, work, and rates of breakdown; the breakdowns amongst the habitual close eye
workers were altogether out of proportion to those amongst myopes not so engaged.
That was evidence of the need of some check. An agreed standard should provide
the check. Cases were far too numerous to allow every case to be treated 4< on
its merits ” irrespective of a standard. Mr. Harman urged the Section to instigate
an inquiry into the matter.

The PRESIDENT suggested that the question of referring the matter under discussion
to the Council of British Ophthalmologists for their consideration should be put to
the vote.

The meeting unanimously agreed that it should be so referred.

1 Trans. Ophth. Soc. U.K., 19*22, xlii, p. 22.

Section of ©pbtbalmolOQS.

President—Mr. A. L. Whitehead, M.B.

A Case of Retinitis Circinata.

By Humphrey Neame, F.R.C.S.

Patient, a male, aged 39.

April, 1922 : Suddenly noticed that he could hardly see with right eye,
and that there was a “ spot M in front of it.

June, 1922: At Central London Ophthalmic Hospital, right vision ,
right fundus showed a fairly large haemorrhage in macular region.

August, 1922: Circular grey swelling above macula in addition to large
old haemorrhage below, and some small haemorrhages.

September, 1922: Very delicate “ milky way ” incompletely around
macular region. Minute white dots—retinitis circinata. Angeioid streaks
in left fundus. Mottled appearance well to temporal side of each macular
region. Central scotoma, right. Field full.

October, 1922 : Retinitis circinata well marked.

The interesting points are the relative youth of the man and the develop¬
ment of the retinitis circinata under observation.

(Coloured drawings shown by epidiascope.)

We thought of various possibilities—an inflammation, a neoplasm, a cyst.
A neoplasm is excluded, because the condition has remained fairly constant for
three months. The question of tubercle was considered. Tuberculin injections
were therefore given (B.E.) starting from 0*00001 mg., but there was no
temperature reaction, and no local exacerbation. Against its being inflam¬
matory in origin is the fact that the surface of this swelling is smooth and
clear, and that the little vessels are sharply defined. The Wassermann test
was negative, and there was neither history nor sign of syphilis. Other pos¬
sibilities are a cyst of the retina, or retinitis haemorrhagica externa of
Coats.

I think the swelling is either a cyst in the retina or an exudative
retinitis with a deposit of fibrous tissue in the seat of a previous
haemorrhage.

The last point of interest in the case is the presence of angeioid streaks ;
as regards the cause of these we have not got beyond the theoretical stage.

DISCUSSION.

Mr. Malcolm Heprurn said that many of these cases of so-called retinitis
circinata had origin in the choroid, for it was there that the original inflammatory
deposit took place. In old cases one could generally find scars at the macula, with

F—Op 1 [Xocentber 10, 1922.

12 Neame: Retinitis Circinata; Hine: Ectopia Lentis

much pigmentation associated with organized outlying exudate. The present case was
in an early stage, and therefore it was an acute metastatic inflammatory deposit ; scar
tissue would develop later. These deposits were also found in many other parts of
the choroid, but were always more intense at the macula. Some part of the retinitis
circinata would clear up, and some would remain as a fibrous or hyaline deposit. At
the present time this formed almost a complete ring.

Sir William Lister said he had had the opportunity of seeing a big choroidal
haemorrhage go through the “ melting snow ” stage which occurred in retinitis circinata.
The patient had had a blow on his eye, followed by a large subretinal haemorrhage in
the region of the macula, w r hich caused a plum-coloured spot, unlike the cherry-red spot
of embolism. Gradually the haemorrhage absorbed, becoming a “ melting snow ” kind
of white area, just as in the case under discussion. Then that area disappeared as it
became absorbed, and disclosed a large choroidal rupture. It was interesting to see
the configuration of white areas, such as occurred in retinitis circinata, as a purely
temporary condition following the rupture. He believed that in cases of retinitis
circinata there was some form of infection which caused the change to become more
permanent; whereas in the case due to a blow there was no infection, and the whole of
the haemorrhage, and the condition following the haemorrhage, disappeared.

Mr. Leslie Paton said the case of this condition shown at the last meeting by
Mr. Williamson-Noble had a positive complement-fixation test to tubercle. He did not
yet know what was the precise value of that test, but those who did the test placed
reliance on it as an indication of tubercle. The lesion in the present case might be a
tubercular nodule, not a cyst.

Mr. Neame (in reply) said he agreed with Mr. Hepburn as to the possibility of a
choroidal origin in some cases of the disease, but not by any means in all. Sir Jonathan
Hutchinson, 1 in his original paper, describing ten cases (the first description published)
held that they were all of choroidal origin, and referred to the spots, from the clinical
point of view', as in the choroid. Most subsequent writers, however, dissented from
this opinion. He thought there must be various causes of retinitis circinata, which he
regarded rather as a physical sign.

Case of Ectopia Lentis (both Eyes).

By Montague L. Hine, M.D.

Patient, a male, aged 6. Congenital abnormality. No other members of
the family affected. No other deformities.

I have brought the patient in order to invite opinions as to what it is best
to do in such cases. What is usually the ultimate end of these cases ? Has
any member seen a case of the kind which has not been operated upon ? Has
a case been seen which has persisted without operation to adult age?
Or does some complication always supervene ?

DISCUSSION.

Mr. A. L. Whitehead (President) said he had operated upon tw r o or three cases of
this kind by fixing the lens with a needle, and breaking it up with another needle.
It was difficult to perform a discission unless this was done first. The cases in which
he had carried this out did well so far as removal of the lens was concerned, but he had
always found the acuity of vision afterwards to be subnormal; obviously there was
some congenital amblyopia associated with defective development, which had caused
the lens to be out of place. He had recently seen a man over 60 years of age with an

1 lioy. Land. Ophth, Hasp. Rrpts., 1876, viii, p. 231.

Section of Ophthalmology

upward dislocation of his lenses, which were developing senile opacities. As the man
could still get about fairly comfortably, he had not yet operated and he was not
looking forward to the prospect of removing a congenitally-dislocated lens which was
the subject of senile opacity.

Mr. T. Harrison Butler said he had operated upon some adult cases cJf this kind,
by the method of an American who wrote an interesting paper on removing dislocated
lenses from the vitreous. The first necessity was to have an extraordinarily good light.
Next, to do a preliminary iridectomy. By using an iris hook there was no particular
difficulty ; then one should wait until the eye settled down. In the last case of the kind
he did, a general anaesthetic had been necessary. There was a corneal incision, and he
had a Smith spoon ready, and the lens came out easily, without loss of vitreous.
Recently the iris had become somewhat drawn up. The operation had been done
five years ago, and the vision was now W* Another dislocated lens, in the case of an
infant, he needled with a Ziegler’s knife ; it was not necessary to fix it; but, up to the
present, there had been no sign of absorption. He thought an injection of novocaine, to
paralyse the orbicularis, w r ould be better than a general anaesthetic. In some cases the
lens slid out easily in a most unexpected way. If left, many of them became dislocated
into the anterior chamber and caused glaucoma; others dropped into the vitreous and
caused cyelitis.

Mr. It. Affleck Greeves remarked that recently he operated upon two cases, and
found that the needling was not particularly difficult. He needled them with a Ziegler
knife, putting the knife in at the periphery, close to the attachment of the lens, and
draw ing it inw’ards towards the centre of the pupil, and there seemed no difficulty in
cutting the capsule. In the last patient he operated on both eyes ; one of them he
allowed to absorb, the other he evacuated, and in both cases the pupil was now* clear.
Vision, though much improved, was still subnormal, about T 6 * or V*, whereas before the
oj>eration it was and could not be improved beyond that.

Mr. D. Leighton Davies said that, in deciding whether one should operate upon
these cases, much depended on whether the edge of the dislocated lens lay inside the
pupillary area when the pupil was contracted. If it just came to the pupil, the case
was better left alone, because he thought there must be some congenital want of
development in the function of the retina also in these cases. If they came within
that, there must be more disturbance of vision, and it w r as always best to needle those
cases. He always fixed them with the needle behind the sclera, pushing the lens well
forward. The best results he had had were to secure Vr after less than ; most of
them got about /*. On the whole it was better to needle than to do a large operation
like an extraction in a young child.

Haemangeioma of Orbit
By Leslie Paton, F.R.C.S.

Patient, a female, age 76, widow. Eight eye, proptosis four years. No
pain “ except occasionally.”

On admission : Eye displaced forwards, downwards and inwards. Lump
to be felt below and external to globe by finger pressed deeply into orbit.
Enlarged right submaxillary gland. Small shot-like gland in right supra¬
clavicular region. Upper orbital margin irregular, result of old fracture.

June 24, 1922: Mr. Clayton-Greene examined the glands and did not con¬
sider them to be malignant.

July 18, 1922: Operation by Mr. Paton. Outer canthus was split to
disclose the tumour, which was removed and the incision sutured.

Tumour was found to be an angeioma. The tumour is a simple cavernous
angeioma. It consists of irregular spaces containing circulating blood and

14 Paton : Haemangeioma of Orbit; Recurrent Detached Retina

lined by endothelium. They are bound together by a loose, fairly cellular
connective tissue.

My main reason for showing this case is that practically none of the cases
which have been described—and Lagrange collected over eighty of them—have
been in pltients over 60 years of age. They have mostly occurred in young
adults under 40 years of age. One theory is that they are of the nature of
congenital nsevi, growing as the age increases. In the case of this old lady I
am showing, there was practically no trace of anything wrong until she was
over 70; she is now aged 76. A complicating point was the presence of
enlarged glands in the neck. She insisted on having something done, and I
told her I would remove a piece of the growth for examination. I started,
but found a growth the size of a walnut, which was encapsuled, and came out
very simply and beautifully; its removal was followed by practically no bleed¬
ing. The present position of her eye is due to cicatricial contracture of the
external rectus. At some date there has been a fracture of the upper margin
of her orbit, and the question is whether in that case there is some connexion
between the injury at that time and the development of this cavernous
angeioma at her late age.

Mr. Humphrey Neame said there was a case at the Royal London Ophthalmic
Hospital, under Mr. Fisher, last year, in which a larger tumour than in this case was
present. The eye was useless, therefore exenteration was performed. Enormous
vessels were found, almost as large as the little finger. In that case there was a
history of a gunshot wound, and of a small metal fragment being retained in the
orbit; the angeioma presumably was started by the injury to vessels.

Case of Recurrent Detached Retina after Seventeen Years’

Reposition.

By Leslie Paton, F.R.C.S.

Patient, a male, was operated upon originally for detachment of
retina in 1904. He had three or four operations performed upon him at
Westminster Ophthalmic Hospital, six at Moorfields, and I have done five
operations on him. Subsequently to the last operation on his left eye he had
obtained reposition of his retina, and has been using that eye from 1904 until
last December (1921). During those seventeen years he has been going about
London with newspapers on a bicycle, threading cleverly through the traffic
as such men can be seen to do, therefore it can be assumed that he has
had fairly useful vision. He has had no restoration of vision in his right eye,
though he had reposition of that retina. Eleven months ago he had a
recurrence of the loss of his sight in the left eye, and I did not see him again
until last month, when I saw he had a large balloon-shaped detachment in the
upper and lower outer quadrant of his left eye. I operated upon him again,
and he illustrates the condition frequently seen in cases of reposited retina
after old detachment. There is very marked pigmentation, and in his left eye
there is still a shallow detachment in the quadrant I did not operate upon,
reaching to 7 d. In the lower detachment there is a fold which runs along
what w r as the inner limit of the detachment in the low 7 er quadrant, but the
retina is back in position over the vdiole low T er quadrant except this fold.

I had another case of recurrence of detachment in a man who w r as operated
upon in 1907. His detachment has been in position since 1907 until this
summer, when he got a shallow detachment below again, that is, a recurrence
after fourteen years.

Section of Ophthalmology

Case of Bilateral Proptosis, with Limitation of Movement

in One Eye.

By R. Affleck Greeyes, F.R.C.S.

Patient, a male, aged 37. The proptosis began a year ago, first the right
eye, then, six months ago, the left. In August he developed double vision.
The condition does not appear to have altered much since, and the double
vision, both in the primary position and when looking upwards, troubles him a
good deal. At first sight the case appears to be one of Graves' disease,
because there is retraction of the eyelids, but there is no other symptom of that
disease, such as tachycardia or swelling of the thyroid. He occasionally has,
however, a slight tremor of his hands. The movements of the left eye are free
in all directions. Upward movement of the right eye is absent, and its inward
movement is a little limited. The right eye is turned downwards, and slightly
displaced in that direction. X-ray examination gives a negative result. No
tumour can be felt in either orbit. Wassermann reaction negative.

Mr. A. L. WHITEHEAD (President) said he thought this was probably a case of
Graves' disease.

Tumour of Right Upper Lid (Angeioma).

By J. F. Cunningham, F.R.C.S.

Patient, a male, aged 14. The tumour has been present for six^months.

Plastic Operation for Contracted Sockets.

By M. W. B. Oliver, M.B.

Patient, a male, admitted to the Queen's Hospital, Sidcup, on August 10,
1921. Very badly contracted socket-loss of lower lid and partial loss of upper
lid. New lower lid made from temporal flap lined by inturned flap from malar
region. Partial new upper lid.

Many attempts were made to make a socket to hold an artificial eye by
epithelial inlays. After each operation the socket contracted again within a
few weeks. Five months ago a very radical operation was performed. The
whole of the orbital contents were removed down to the periosteum. A very
large inlay was inserted. For two months after this a vulcanite mould attached
to a dental splint was worn. There has been no tendency to contract, and a
large artificial eye can now be worn.

It is a modification of the old method of treating a contracted socket by an
epithelial inlay over a wax mould. The objection to this is, that many of the
sockets contract again, whatever one does, and there is a discharge which persists
for years. In all these cases I remove the whole of the conjunctiva, including
that of the lids themselves. I think such an operation could be adopted in
cases of exenteration of the orbit; there is no reason to remove the lids in such
cases. And when the cavity is skin-grafted, it is very important to skin-graft
the under surface of the lids.

16 Juler: Retinal Degeneration, with Mental Deficiency

Case of Retinal Degeneration, with Mental Deficiency.

By F. A. Julee, F.R.C.S.

Patient, a girl, aged 15. I think this case must be of the nature of
retinitis pigmentosa. The patient has definite mental deficiency, and there
are other unusual features. The disease seemed first to affect the macular
regions early. She came with the history that vision had been very defective
for three years. She was first seen about nine months ago ; at that date there
were fine changes in both maculae, and some degeneration in the periphery of
the retina—a small pigment change there. The optic discs were pale, with the
waxy type of atrophy. She has been coming up at intervals since, and there is
some progress in the degeneration ; the pigmentary changes are more marked
in the periphery of the retina than they were. There is no family history of
blindness. In the patient there is no evidence of syphilis, but the mother
gives the history that she has had two other confinements ; in one she had a
premature child, and the child of the other confinement died in fourteen days.
So there is a possibility of syphilitic defect here, though the patient’s Wasser-
mann reaction is negative. She was in the lowest standard at school before
her sight became bad, when her age was probably 10 or 11. Now she attends
a blind school, but she cannot pick up the work as the other children do. Her
mother admits the child is mentally dull. There is no consanguinity in the
parents.

Section of <$>pbtbalmoloav>.

President—Mr. A. L. Whitehead, M.B.

Night Blindness ; Retinitis Pigmentosa sine Pigmento.

By J. A. Valentine, M.D.

W. A. K., AGED 26. Sight failing since 1915. No relatives with similar bad
sight. Eight vision, % ; left vision, tV King scotomata. Pupils normal and
media clear. Discs show indistinct margins. Vessels slightly smaller than
normal.

Fundi: (1) Outer zone in periphery shows thinned chorioids. Only large
vessels of chorioids remain. (2) Intermediate zones : Some thinning of chorioids.
Large veins visible with interspaces filled with dust-like pigment deposits. (3)
Macular areas appear normal except that the maculae themselves are not visible
as distinct from rest of foveae. Small bright specks are seen here and there,
apparently on anterior of retinae. In the left fundus one or two small
collections of pigment of the “ bone corpuscle M variety are seen on the
nasal side.

Though the patient complains of night blindness, this is due to his
tubular vision, and not to a deficiency in light sense, as his light minimum
and light difference are normal at the fixation area, as tested by Percival’s
rotating discs.

Case of Amaurotic Family Idiocy.

By A. H. Levy, M.D.

E. D., FEMALE, aged 1 year 7 months. Family history: Parents are first
cousins. Father (aged 27) born in London of pure British parentage; grand¬
parents British. Has never had any specific disease or serious illness.
Mother (aged 24) of London birth ; previous history good. Family antecedents
for two generations also non-Jewish. One other child, aged 3, healthy. No
miscarriages.

Patient’s history: Full term child, normal labour and delivery. Weight
at birth, 7 lb. Breast-fed up to the age of 10 months, then with cow’s milk
and water. Brought to hospital on account of having a “ weak back ” : could
not sit up ; there was difficulty in weaning. After the seventh month the child
lay in any position in which it was placed, and was very quiet during the day
but noisy at night. When 4 months old the patient had a fall, causing “ black
eyes,” but she soon recovered. On September 6, 1922, she was admitted to
hospital, weight 111b. 10 oz. On admission: Fairly well nourished; looked
“ vacant ” ; did not perceive light, but was very sensitive to sudden noises.
Lay quiet, and appeared only to eat and sleep: uttered a strange plaintive
cry when hungry; could not sit up; head rolled from side to side. Anterior
My—O r 1 [January 12, 1923.

18 Levy: Amaurotic Idiocy; Hine: Maculo-cerebral Degeneration

fontanelle widely open. No teeth. Knee-jerks brisk ; Kernig’s sign indefinite ;
no clonus. Eyes: No perception of light; discs atrophic, white with clear cut
edges. Vessels normal in size. Maculae occupied by white area with circular
red spot in centre.

Present condition : The child is much wasted; spasticity increased; is
unable to sit up unsupported ; cannot take any food except liquids. Auditory
acuity marked ; four teeth now appearing; fontanelle still widely open.

DISCUSSION.

Mr. LESLIE PATON reminded the Section of a case of this condition which Dr.
Wilfred Harris showed in 1913, in which no Jewish parentage could be traced on
either side ; the family lived in Bayswater. About eighteen months ago an excellent
paper was published on the subject by Bielschowsky, 1 which dealt with the changes
in detail, and it was interesting to learn to how great an extent the cerebellar cells
participated in the change. He pointed out that there were marked differences
in the extent of macular cerebral and cerebellar disturbance in different cases.

Mr. TREACHER Collins said that Sir Frederick Mott had shown that not only
the ganglion cells of the cerebellum and cerebrum, but the ganglion cells all over
the body were affected in this disease, even those in the sympathetic system. It
was of great interest to see, on one evening, cases illustrating two different forms
of retinal degenerative change: amaurotic family idiocy, which began in the ganglion
cells of the retina, and pigmentary degeneration at the macula, which began in the
cones. Often these two conditions were confused, but to-night they had the
opportunity of comparing the difference in the ophthalmoscopic appearances which
they presented.

Two Cases of Early Familial Maculo-cerebral Degeneration.
By Montague L. Hine, M.D.

Case I. —C. C., MALE, aged 16. I first saw this, the elder boy, three years
ago. He commenced having epileptic fits when he was 10 years of age, and he was
treated in the ordinary way with bromides at London Hospital. His vision
was defective, and he went to another hospital, where he was supplied with
glasses. As he still could not see, even though his glasses were correct, he
came to me at the Miller Hospital for examination. The maculae were very
finely granular, and I took him to the Royal Westminster Ophthalmic Hospital,
as I thought he was suffering from maculo-cerebral degeneration. Dr. Gordon
Holmes confirmed that view, and the patient went into Queen Square Hospital
for some time. The Wassermann reaction was negative, and there was nothing
in the family history to suggest syphilis; there is no parental consanguinity.
He has been going downhill, and to-night his cerebration is very sluggish,
he is almost paralysed, and there is incontinence of urine, but not yet of
faeces.

Case II. —A. C., male, aged 10. Twelve months ago the younger brother of
C. C. was brought to see me, not because there was anything the matter with him,
but because the parents wanted to know if there might be. His vision was found
to be tV in each eye, and it could not be improved by glasses. He had a very small
refractive error, and both his maculae were finely granular, the left rather more
so than the right. I then said—though not every one who saw him agreed—

1 M. Bielschowsky, “ Zur Tlistopathologio und Pathogcnese der Amaurotischen Idiotie” ;
Jour. f. Psychol, u. Neurol., Leipzig, xxvi, 123-190.

Section of Ophthalmology

that the state of his fundus was very suspicious, in view of the family history
and the non-improvement in the vision. I sent him to Dr. Gordon Holmes,
who found no changes in the central nervous system, but on October 10 last
he had an epileptic fit (so called). He was then the same age as his brother
was when his fits had begun. Next day he was brought to hospital, and his
fundus was exactly as you see it now, the same in each eye, with very fine
granular pigmentation of the right macula, rather more marked in the left
macula. Since that time he has had three additional fits, and there can be no
doubt that he is going the same way as his brother. There is another brother,
now aged 18, who, the mother says, is quite well, and has no trouble with
his sight. I have not yet been able to see the other children. There is
one brother, between the patients in age, who is not affected; also two sisters
and one brother, younger than A. C., who are not affected.

Dr. Rayner Batten agreed that these cases were definitely of the cerebro-
macular type; but the pigmentation was not so marked as in the other cases of
the condition he had seen. Here it was a fine granular pigment. He thought the
present cases were of the juvenile familial type, not the infantile; he considered
there was a distinction between the two. It w f as very remarkable how, in the juvenile
type, the disease came on at a particular age, i.e., somewhat bordering on the age
of puberty. There was another class also in which pigmentation occurred, but
without the cerebral symptoms. That formed the second class, in the juvenile
sense.

Case for Diagnosis (? Polycythaemia Rubra).

By Percy Bardsley, M.B.

This lad came to me complaining of great fatigue. He is a theological
student, and he complained that he could not work more than four or five
hours a day. At the time when he was supposed to play games with the other
students, he usually went to bed, and he had the greatest difficulty in getting
up in the morning. He was conscious of mental as well as of bodily lassitude.
I corrected his refraction error, which was very slight, but in a fortnight
he returned and said he had double vision. I then examined him more carefully.
His medical man had been treating him as a neurotic subject. I was struck
by the condition of both his veins and his arteries, and particularly by the
brightness of the veins. I wrote and asked his medical man to have a blood
examination made. This was done, and it was found he had 7,600,000 red cells,
a very slight increase in haemoglobin, and a slightly diminished colour index.
I have noted down the condition as “ ? polycythaemia rubra.” I have read
through Dr. Parkes Weber’s book, 1 and I cannot see that this agrees with his
cases in all particulars ; the patient is younger than any mentioned in that
book, with the exception of three girls, and in all of them there was a very
abnormal menstrual history, connected mostly with a tubercular uterus.

This patient has no enlargement of the spleen or liver, so far as his medical
man can detect; he is not aware of having had syphilis, and his Wassermann
reaction is negative. I think it possible he has always suffered from a con¬
genital excess of bone-marrow. He says that from his earliest days he has
been subject to periods of great lassitude, and that these have always been
followed by severe diarrhoea, after the cessation of which he has been better
for a time. He was in the Army three years, and during that time his health

i “ Polycythannia, Erythrcevtosis and Erythremia (Yaqiiez-Osler Disease),” 1921.

20 Bardsley: ? Polycythaemia ; Rea: Hole in the Hyaloid

appears to have been normal; he was passed as A.l. But on returning to
Salisbury he again experienced this lassitude and lack of energy. A physician
diagnosed that he was suffering from some form of colitis, and he has been
treating the patient for this; the patient certainly seems better, though the
condition of his blood has not altered. If it is polycythaemia, I am afraid
the prognosis is bad, but I shall be glad of information as to the nature
of the case.

At the last meeting the treatment recommended to me was frequent
venesection, even up to 30 or 40 oz. to be carried out every few months. This
seems drastic, but, according to Parkes Weber's book, it is the only treatment
which has produced gratifying results.

DISCUSSION.

Mr. A. L. WHITEHEAD (President) said he considered that the veins of this patient
were abnormally distended, and that the whole fundus and disc were hypenemic,
though he could not say that the degree was in excess of ordinary physiological limits.
He did not detect any haemorrhages. Had venesection been done since the last
meeting ?

Mr. Treacher COLLINS asked whether there had been fundus changes in any
other cases of the kind which had been recorded.

Mr. BARDSLEY (in reply) said that no treatment had been adopted since the last
meeting, as the patient had been on his holidays, and had only returned in time
to show himself at this meeting. In Dr. Parkes Weber’s book the ophthalmoscopic
appearances in a few cases were described, and the extreme distension of the veins and
their bright blue colour were commented upon.

Case of Hole in the Hyaloid.

By R. Lindsay Rea, M.D., F.R.C.S.

This case came to my notice three years ago. Vitreous opacities were
present so that I could not make out the fundus details. I watched the case
closely at three or four weeks’ intervals. Sometimes I could see the fundus ;
next day it would not be visible. The Wassermann reaction of the hlood was
strongly positive, so I had the patient placed under proper treatment ;
injections of novarsenobillon were given, followed by mercury and iodides.
The vitreous bodies then began to clear, and when I could see the left fundus
I found a ring in front of the optic disc. I sent the case to Sir William Lister
who agreed it was a true case of “ hole in the hyaloid.” During the last year
I noticed that the ring was shrinking in size and that it was anchored.

In his paper on “Detachment of the Vitreous” which Sir William Lister
sent to the Washington Ophthalmological Congress and communicated by
Mr. Treacher Collins, the statement is made that the vitreous body is attached
most strongly around the ora serrata. Professor Johnson Symington, in
Quain’s “ Anatomy,” vol. iii, pt. ii, quotes Iwanhoff and Stuart as supporting
this view, but Symington states on page 253 that the vitreous can be readily
separated from the retina except behind, at the entrance of the optic nerve,
where the connexion is closer, the retinal vessels having here entered it in
foetal life.

The only explanation I can think of in the case is, that owing to shrinkage
of the diseased vitreous, the attachment to the optic nerve, which, normally

Section of Ophthalmology

not visible, was made visible and showed as a ring of connective tissue, was
dragged away from the optic disc. There is no doubt of its stationary
character for during the past year it has not altered its position.

DISCUSSION.

Mr. Treacher Collins said he had always been very sceptical about the
occurrence of holes in the hyaloid, until he came across this present case, which
was a very definite instance of the condition. There could be very little doubt that
in it the vitreous had become torn away from the optic disc, and at the spot where it
had been attached a circular hole had been left. Sir William Lister had a very
beautiful drawing made of the case, which was shown in connexion with his paper at
the Washington Congress, and was published in its Transactions.

Mr. Gimblett said that whilst he was seeing cases in the examination room of the
Ministry of Pensions he saw' a case with a similar appearance in the vitreous, but in
that case the ring was four times the diameter of that in the case now r show n. It could
be seen with a + 6 D. lens. Two days later he saw’ another case of the same kind, but
had not been able to trace the second one since. In the light of the explanation given
that evening, the ring seemed to have been, in those two cases, exactly the size it would
have been if it had come away from the optic disc behind.

Mr. Lindsay Rea also showed a “Case of Papilloedema with Detached
Retina in each Eye, in a Young Woman, aged 22.”

Some Unusual Results of Operations for Cataract.

By T. Harrison Butler, M.D.

Case I: An Example of Total Aniridia following a Preliminary Iridec -
This must be a very rare accident, and I have never seen it before,
^hen I have a reliable assistant I adopt the old-fashioned plan of allowing him
to cut the iris. In this case, that of a woman, aged 74,1 made an incision with
a narrow bent broad needle and withdrew the iris. My assistant attempted to
cut the iris, but the de Weekers scissors failed to cut. While he took up another
pair from the tray I held the iris quietly in the forceps, and the section was
made cleanly. During the time that the iris was held prolapsed there was no
indication of any detachment and no haemorrhage. The patient did not move.
As soon as the iris was cut the whole anterior chamber filled with blood and
I saw nothing more. I found that the systolic blood-pressure was 200 mm. of
mercury which appeared to account for the haemorrhage. A month later the
anterior chamber was still full of blood and the tension of the eye was somewhat
raised. Two months after the operation the blood had become absorbed, and I
noted that the iris was totally detached from the periphery and lay rolled up
>n the vertical diameter of the anterior chamber. The lens was exposed and
^as seen to be very large. I did not extract the lens but removed the cataract
from the second eye with favourable result.

It is difficult to account for this accident. No unusual traction was made
upon the iris: I wonder whether the fact that the iris was held prolapsed for
several seconds can in any way account for the catastrophe.

22 Butler: Some Unusual Results of Operations for Cataract

Case II. —This is one of mistaken diagnosis, but at first it appeared to be
an example of clearing of a cataractous lens. It is of interest because it offers
an explanation of cases which, if not reported in responsible journals, have been
at any rate talked about. It is questionable whether a real cataract can ever
clear without absorption. It is said that a diabetic cataract may again become
clear, and that a traumatic posterior capsular cataract may disappear.

In this case, the woman, aged 71, came to the Coventry Hospital in April,
1921. She was examined by Dr. Brazil, my assistant, there. He made drawings
of the lenses, and noted complete cataract in the right eye and lens striae in the
left. There was a history that the sight had slowly failed during the past year.
We have no note of any injection or pain. I made a note shortly afterwards
that there was general deep-seated opacity of a brown colour in the right lens.
The right fundus was invisible. There were striae in the left lens and here the
fundus was visible and normal. The acuity of the right eye was reduced to
hand movements.

On May 25, 1921, preliminary iridectomy was performed upon the right
eye. The operation was not followed by any reaction. Two months later
there was still some red reflex, but no fundus details could be seen. At this
time I still had no idea that I was not faced with an ordinary opacity deep in
the lens. On November 7 I made a note: Right fundus dimly seen, but I had
no suspicion of the true state of affairs.

I did not see the patient for another year, but she reappeared on
October 16, 1922. I found that the fundus was clearly visible and that with a
suitable correction the acuity was tV and J 1! I was now able to examine the
fundus with care, and I found floating opacities in each vitreous. In the right
eye there was well developed arterio-sclerosis, and one of the sclerosed arteries
became quite white as it neared the “north-west ” periphery. Here I found
several silver wire twigs and marked sclerosis of the choroidal vessels with
punctate haemorrhages.

I think there is no doubt that the original condition was not cataract but
a haemorrhage in the anterior portion of the vitreous which had slowly become
absorbed.

Case III.—One of Total Absorption of a Cataractous Lens in a man aged 46 .
A preliminary iridectomy was performed on April 28, 1921, by my house
surgeon. I w r atched very carefully and I am certain that the keratome did not
touch the lens, nor do I think that the iris forceps could have done any damage.
There was considerable reaction after the operation, and eventually some
keratitis punctata was seen. I had a blood count made and this showed an
increase in the lymphocyte count (large 20 per cent., small 20 per cent.), but
none in the large hyalines. For some time I was anxious with regard to
sympathetic ophthalmia, but decided to watch. A fortnight after the operation
I noted that there was a notch in the upper aspect of the lens. The eye
remained injected for five months; after that time the inflammation subsided.
The notch in the lens began to increase rapidly and at the end of six months
the whole lens had absorbed, leaving a perfectly clear view of the fundus.
With a plus 10 lens an acuity of tV was obtained.

Case IV. —Some years ago I did a preliminary iridectomy upon a private
patient. A small iris encleisis was left. When I came to perform the extraction I
made a point of trying to clear away this iris attachment. The wound appeared to
heal soundly and the patient returned home with an acuity of •§. She returned
in two months showing a large iris prolapse. She said that a dark bleb formed

Section of Ophthalmology

on the eye which eventually burst and the sight went. I excised this prolapse
and covered the site with a conjunctival flap. The wound healed again firmly
with no sign of prolapse but the tension remained low and the acuity did not
return. She returned home, and I heard no more about her for seven months
when I was told that she had suddenly developed acute glaucoma, and had to
have an operation to relieve it. This case is interesting for two reasons. It
shows what I have noted in other cases, that a very small iris encleisis may
begin to bore its way out and grow to a large prolapse, and that an eye which
has for some time showed low tension from a filtering scar may, if the scar
cease to filter, suddenly develop an acute glaucoma. I had an example in a
man whose cataract wound refused to heal for a fortnight. It eventually closed
and an acute glaucoma developed which was cured by expectant treatment.

My next two cases deal with Excessive Post-operative Astigmatism.

Case V .—I extracted the lens of a man, aged 65, in March, 1920, and fitted
him up with a plus 10 sphere and plus 2 cylinder. He now had a severe
attack of pneumonia and was nine weeks in hospital. In October with
plus 10 and plus 2*5 the acuity was The following January he took a
6 sphere and a 6 cylinder, and in March a 4 sphere and a 10 cylinder,
with an acuity of xV The second lens was removed, and he was given the
usual 10 and 2.

This is an example of a gradually increasing astigmatism at the expense
of the sphere. I have never noted this before, whereas tho reverse change is
very common. Placido’s disc showed distinctly oval rings, long axis
vertical.

Case VI .—Another case, that of a lady, aged only 50, shows that very
powerful cylinders can be worn with comfort, and that they give good acuity.
I extracted the right lens, and had a good deal of trouble during con¬
valescence from haemorrhage into the anterior segment of the eye, which
came on the third day. At one time I feared that the eye would be lost,
but happily all cleared up, and there has been no further trouble. With plus
B sphere and plu3 11 cylinder the acuity is £. This was reduced eventually to
plus 11 and plus 9.

I extracted the second lens under a conjunctival bridge, and the final
refraction was plus 8 sphere and plus 14 cylinder. This correction gives §
acuity. My optician tells me that his firm have never ground a cylinder as
high as this. Eetinoscopy gave 25 in the vertical and 10 in the horizontal
meridiap. The Placido figure was at first an oblong with rounded corners, but
dow it. is a perfect ellipse. I make a practice of examining all my extractions
with Placido's rings, which often afford valuable information regarding the
shape of the cornea.

Case VII .—My final case—the patient a female, aged 50—is one in which
a mild sympathetic ophthalmitis took the form of a subacute glaucoma.
After the extraction a chronic irido-cyclitis set in, and I wished to remove the
eye. This was refused, and one of my colleagues thought that I might
wait and watch the case. Suddenly in one night the second eye became
ve *7 painful and completely blind. I found that the tension was raised to
80 Schiotz units. I at once removed the eye that I had operated upon, and
began a course of massive doses of salicylate of soda and injections of
novarsenobillon. Fine keratitis punctata developed. I tried atropine and

24 Butler: Operations for Cataract; Killick: Conical Cornea

then eserine, but neither seemed to influence the tension, which gradually
settled down, but was not normal for several months. The sight gradually
returned, and is now jV There is sufficient lens opacity to account for this
lack of full acuity.

I have seen other cases in which sympathetic ophthalmia of a mild
type took the form of a semi-acute glaucoma with minimal signs of
inflammation.

DISCUSSION.

Mr. A. L. Whitehead (President) said that Mr. Harrison Butler had courageously
brought forward accounts of cases such as probably most members had had, at some
time or other, and it was very instructive to hear of instances in the experience of
others. In regard to the case which was operated upon by the house surgeon, he
asked whether there had been damage to the lens or not. It ended with A vision;
was that after the lens had undergone absorption ? The point had been raised as
to prolapse of the iris occurring some time after operation. He (the President) had
seen that twice: a very minute piece of iris had been caught in the scar, and was
represented by a very minute black dot; some months later a definite prolapse
appeared. With regard to the extraordinarily high degrees of astigmatism, he
asked whether these were all cases in which the conjunctival bridge operation had
been done ?

Mr. TREACHER Collins said that with regard to the cases Mr. Harrison Butler
had just related, he agreed that there must have been vitreous haemorrhage in the
case in which a preliminary iridectomy was done. It was said that diabetic
cataracts sometimes cleared up; he (Mr. Treacher Collins) had not known them
do so; but as so accurate an observer as Mr. Nettleship had reported such a
clearance it must be regarded as a possibility. He (the speaker) did not think senile
cataract ever cleared up, though the fluid in a Morganian cataract might sometimes
diffuse through the capsule. He agreed that a small black point at one angle of the
scar, due to the entanglement of a knuckle of iris tissue at the angle of the coloboma,
might after some weeks or months become a bulging cicatrix. He had known this
happen. Mr. Treacher Collins thought that astigmatism after cataract extraction,
which progressed in the way described was usually due to failure in complete
union of the posterior lips of the wound from entanglement of lens capsule.

Mr. Harrison Butler (in reply) said that in the case operated upon by the
house-surgeon the lens was completely absorbed; he did not think that it was damaged
during the operation. In the high astigmatism cases, one eye in each patient was
operated on by the bridge method, the other was not.

The Treatment of Conical Cornea.

By Charles Killick, M.D.

(ABSTRACT.)

The author remarked that slight and early cases of keratoconus were
seldom seen and possibly overlooked. His own experience had been of late
cases in which the disease was advanced, and something had to be done by
way of operation. After stating that keratoconus might occasionally be
unilateral, he quoted a series of six cases recently under his care. Five of these
were in women, including two pairs of sisters. One female patient was an

Section of Ophthalmology

idiot and the solitary male was a young and healthy adult. The disease was
probably developmental in the two latter cases, in the others it had shown
a tendency to appear in more than one member of the family. After briefly
alluding to the pathology and theories of causation the treatment was
considered. In two cases a pressure bandage was applied where the apex
of the cone had become opaque, with the result of almost completely restoring
normal transparency but, as might be expected, without altering the shape
of the cone in any way. In one other case six operations upon the right
eye were performed, without the slightest benefit. These were in order:

(1) Sclerectomy—interval of eight months ; (2) first stage of cataract extraction
—interval of one month ; (3) cauterization with perforation—interval of
one month : (4) cauterization with perforation—interval of seven weeks ;

(5) cauterization only, over rather larger area—interval of seven weeks;

(6) cauterization with perforation. The final result was a small buttonhole
iridectomy due to the first operation and an insignificant corneal macula.
The patient subsequently developed phthisis.

In a second case, to which Mr. Killick particularly wished to draw
attention, the patient, aged 49, suffered from double keratoconus, and from
a few peripheral opaque striaB in both lenses. Vision was less than The
treatment he adopted was : (l) Expectant for a year—no improvement;

(2) simple extraction of right lens, by subconjunctival method ; (3) small
vertical discission of the capsule, based on the old operation of iridodesis,
namely, that of making a narrow linear opening in the pupil, resembling
a stenopaic slit; (4) correction of refractive error subsequent to operation
by — 5*00 sph. together with — 1*00 cyl. ax. 180°. Vision in the foregoing
case was improved to and the correcting lens indicates an antecedent
myopia of 32 diopters. The author suggested that the above was the operation
of choice in suitable cases and was preferable to any operation involving burning
of the cornea. He claimed that it was: (1) easy to perform ; (2) involved no
disfigurement; (3) could be carried out in a reasonable time; (4) definitely
improved vision.

DISCUSSION.

Mr. A. L. WHITEHEAD (President) said he had seen the second case which
Mr. Killick had described, at Bradford, and the result was certainly striking and
satisfactory ; so also was the pupil which was left; it had dilated a little and was oval,
instead of being a linear slit. One knew these patients saw well through a small
opening, as well as through a slit; and if one was fortunate enough to have a dense
homogeneous capsule, it might be sufficient to make a small hole only.

Mr. ELMORE Brewerton said he had been disappointed with the older methods
of dealing with conical cornea. He had had some good results with the cautery,
but he did not care to attempt the removal of an elliptical piece with many weeks’
delay in healing. He believed that most exponents of this method had given it up.
The method he now adopted was to make a crucial incision through the apex of the
cone, the first incision being made with a von Graefe knife and the two lateral incisions
with scissors. If the apex of the cone was below the centre the first incision should be
downwards and in at an angle of 45° to the vertical and about 6 mm. in length ; the two
lateral incisions on either side of the centre of the first and at right angles to it, and
each about 3 mm. in length. The wound healed in three or four days ; there resulted
a certain amount of flattening and a blurred apex to the cone. The operation was
advisable for advanced cases of keratoconus; he would not hesitate to do it on any case
in which the cone was increasing. He had operated on five such eyes, and in all had

Killick: The Treatment of Conical Cornea

secured improvement in vision. He thought it was better to deal with the cornea
rather than with the lens, in the complicated way described by Mr. Killick.

Mr. KILLICK (in reply) said he agreed that the smaller the opening made in the
capsule the better, and in the next case he had he would make it as small as possible.
The method of dealing with conical cornea described by Mr. Brewerton had not
occurred to him; any method which would supersede the ordinary burning method
would yield better results in the long run.

Section of ©pbtbalmolo ^. 1

President—Mr. A. L. Whitehead, M.B.

Optic Atrophy after Herpes Ophthalmicus.

By Leslie Paton, F.R.C.S.

Mrs. W., aged 67. Sent to St. Mary's Hospital, by Dr. Vincent, of
Strood, Kent, in the beginning of December, 1922. The history was that at
Easter, 1922, she had had a bad attack of ophthalmic herpes affecting all the
branches of the first division of the fifth nerve on the left side. There had
been several vesicles on the cornea, which have left faint nebulae. On recovery
from the herpes she found that the vision of her left eye was lost.

When first seen : Right vision: ^ l^D.^yi, ax. fob = Left vision : Hand

movements. Field evidently very limited. Left pupil does not react to direct
stimulus, but reacts well on consensual stimulus. Reacts slightly to con¬
centrated light. The ophthalmoscope showed an opaque white disc, with
fairly clean-cut edges. Lamina cribrosa not seen. No obvious disturbance of
retinal pigment round edges of disc. Vessels reduced in calibre.

The occurrence of true optic neuritis as a complication of ophthalmic herpes
is comparatively rare. Personally, I had never seen a case with this complica¬
tion until last summer when, through the courtesy of Mr. Adams, of Oxford,

I saw a private case of his, a lady, aged 35. She had had shingles in the right
side commencing on May 15. The whole first division of the fifth nerve was
affected. When the eye was opened again after the attack of herpes had
subsided, it was found that she had gone completely blind in that eye. The
pupil was semidilated and not reacting to light at all. When I saw her, she
was still slightly under the influence of atropine so I was not able to confirm
tbe question of pupil reaction. Her tension was quite normal. There was
no perception of light. Ophthalmoscopic examination showed an entirely
atrophic disc. I understand that there has been absolutely no recovery of
vision in this case of Mr. Adams.

The occurrence of these two cases in my experience within a few months
°f one another led me to look through the literature dealing with this
subject. I found that quite a number of such cases have already been recorded.
Sir Jonathan Hutchinson, in his classical account of the condition, when he
first clearly differentiated it, showed its nature and described its clinical
history. He gives one case of blindness resulting from an attack of ophthalmic

^ Cliuical Meeting, held at the Iioyal London Ophthalmic Hospital (Moorflelds), February 9,
Jt-Op 1 #

28 Paton: Optic Atrophy after Herpes Ophthalmicus

herpes. 1 * 3 * * He lays stress on the fact that the globe is never affected except in
cases where the nasociliary branch of the first division of the fifth nerve is
affected. This, known as “ Hutchinson’s law ” is, however, like so many
laws, subject to exception. The following is Hutchinson’s own statement of
the law*: “ All the cases I have yet seen support the opinion I have expressed
that it is only when the side of the nose is affected that any serious inflamma¬
tion of the eye ensues and that in the worst cases the vesicles will be found
on the very tip of the nose, the part supplied by the oculo-nasal nerve.”
Personally, I have found that, though Hutchinson’s law may be subject to
some exceptions, it is of very great service in prognosis, and I look first of all
to see whether there is evidence of invasion of the side of the nose by vesicles,
and if it is free, I feel more confident in my prognosis as regards ocular
complications.

Some time in the year 1867, Bowman 8 reported another case, left herpes
with optic atrophy, and in the same volume, Hulke 4 records a case in which
optic neuritis preceded by a few days the development of herpes, but in these
Cases the herpes was probably secondary in character and not a primary acute
infective herpes.

The next case that I can find is a case of Daguenet, recorded as 11 Zona
ophtalmique avec n6vrite optique du c6t6 correspondant. 776 In this case
during the acute stages vision was reduced to bare perception of light, but four
weeks later, the vision was recorded as being one-sixth. Gould in 1888
recorded a case in an American publication (The Polyclinic ), but I have not
been able to see a copy of it. I cannot find any further record until a case
recorded by Wangler in an inaugural dissertation at Zurich, in 1889, but,
unfortunately, I have not been able to obtain access to a copy of this.

In 1893, Haltenhoff, 6 recorded a case in which there was haemorrhagic
retinitis, associated with herpes. From the description of the case it seems
almost certain to my mind that there had been a thrombosis of the central
vein of the retina, because the haemorrhages were most profuse, involving
the whole retina except the macular region. The veins were very dilated
and tortuous, and obscured in numerous places by haemorrhages, and the
arteries were reduced in calibre. There was, however, very little evidence of
any swelling of the disc.

Sulzer, in 1898, 7 recorded a case of double optic neuritis, more severe in the
right than in the left eye, with right herpes. The fact that there were three
recurrences points rather to the conclusion that this was not an ordinary case
of primary herpes but rather a herpes associated with some other intracranial
condition. As Sir Jonathan Hutchinson points out, in true herpes there is no
liability to a recurrence of the disease. In cases where recurrences are
frequent, it is more likely that these are what I should term “ secondary
herpes.’ 7

Antonelli in 1902 recorded another case and at a meeting of the American
Ophthalmological Society in June, 1919, Dr. Clarence Veasey recorded a case

1 Ophthal. Hosp. Bepts ., 1866, v, p. 191.

3 Ibid., 1869, vi, p. 48.

:l Ibid., 1869, vi, p. 1.

4 Ibid., 1869, vi, p. 106.

3 Bec.ueil Ojiht., April, 1877.

8 Antiales d'Oculistique, 1893, cix, p. 201.

" Ibid., 1898, cxix, p. 101.

Section of Ophthalmology

in which on the seventh day of an attack of right ophthalmic herpes vision was
lost in the right eye except for a small portion in the upper field, the loss
beginning as a central scotoma and gradually spreading without evidence of
ophthalmic changes or of corneal involvement. A month later some vision
was restored in the peripheral field and the patient could count fingers at 2 ft.
The first nerve was quite pale and atrophic and subsequently all vision was
lost. In this case, then, the neuritis was evidently retrobulbar.

Evidence of other cranial nerve involvements is much more frequently
found. I have had myself three or four cases of diplopia during the epidemic
this last spring, and in the summer I saw one case in which the sixth nerve
was involved, though undoubtedly, from the statistics, the involvement of the
third nerve is very much more frequent. Some involvement of the nerve
supply of the iris and ciliary muscle is also not uncommon, though it is more
usual to find a very small pupil than a semidilated pupil. I have at present
under my care a patient with a most severe attack of ophthalmic herpes with
no portion of healthy skin on which you could put down even a pin head.
Her cornea has so far remained quite clear. There does not seem to be any
more ptosis than could be explained by the drooping of a swollen lid but she
has an extreme degree of miosis in that eye.

I shall not refer to the other complications, though I have at present a very
interesting case in which there was no superficial vesicle on the cornea but a
well-marked deep keratitis with irido-cyclitis. I have seen definite hypotony
in connexion with this last year’s epidemic and this is especially interesting
as numerous speakers at the American ophthalmic meeting in 1919 referred to
an association of raised tension with herpes. Undoubtedly the majority of the
cases in which the tension is raised are cases in which the iris and the ciliary
body are involved in the congestion. In the majority of cases it is the supra¬
orbital and the supratrochlear branches of the first division of the fifth nerve
that are affected. The nasociliary and the lacrymal division are not so
frequently affected, but I have seen within the last six weeks a case in which
the whole of the first division and the whole of the second division of the fifth
nerve were affected, and Letulle, in his article on paralysis of the facial in
ophthalmic herpes, 1 gives a case of ophthalmic herpes associated with paralysis
of the seventh.

So far as the evidence goes, I think the indication is that the changes in
the optic nerve are secondary to the peripheral changes in the circulation
produced as the result of the herpes.

I have once or twice spoken of herpes as being secondary or primary. I
think it i9 most important that we should be very careful to differentiate those
cases in which the herpes occurs as the result of the implication of the Gasserian
ganglion, or of the branches of the fifth nerve, by any other associated intra¬
cranial condition, from the true cases of herpes ophthalmicus, due probably to
an infection of the Gasserian ganglion.

As regards the relationship of this infection to chicken-pox, we are very
much in need of further information. There is an increasing body of evidence
in favour of the association of epidemics of herpes with epidemics of chicken-
pox. It may be within the recollection of some of you that some years ago
I showed a case of optic atrophy resulting from retro-bulbar neuritis during
chicken-pox,* and I have been able to trace in several cases a definite relation-

1 Archives de Physiol ., 1882, ix, p. 162.

a Proceedings , 1917-18, xi (Sect. Ophtb.), p. 12.

30 Ford: Intracranial Tumour causing Quadrantic]Hemiopia

ship between cases of ophthalmic herpes developing in adults with cases of
chicken-pox in children.

DISCUSSION.

Mr. Ransom Pickard (Exeter) said that some years ago he was called to see the
most extreme case of herpes ophthalmicus he had ever observed. In that case the
whole left side of the forehead was sloughing, and the patient was completely blind in
that eye. The condition of the cornea did not allow him to inspect the state of the
nerve, and he did not see the patient any more; the doctor, however, told him the
blindness was complete and persistent. With regard to the relationship between
chicken-pox and herpes, he had a most interesting case under his care for some
time, that of a child, who had had chicken-pox, and with it a persistent paralysis
of the pupil. The paralysis persisted for at least a year. In the South-west of
England it was common knowledge among the people that there was an association
between small-pox and herpes.

Mr. W. H. McMullen said that he had at present under care a case of optic
atrophy following herpes. He did not see the patient while he was suffering from the
herpes. The history was supplied by the doctor who attended him. In July last the
patient had very acute right herpes ophthalmicus, and the eye was very congested and
painful. There was also severe constitutional disturbance, for he was delirious during
two or three nights. By September, when he (Mr. McMullen) first saw the patient, the
affected eye had only perception of light. There were a few spots of keratitis punctata,
which were probably fairly old, as many of them were brown, and the disc was some¬
what pale. Since then the disc had become paler, and now was white, though not of
such an opaque white as in the case Mr. Paton had just shown. The appearance was
more that of a primary optic atrophy, and the difference in the appearance could
probably be explained by assuming that the retro-bulbar neuritis affected the nerve
further back in the eye, and the optic disc itself was less affected.

Mr. G. M. Kendall, speaking of the connexion between herpes and chicken-
pox, said that when he was a child he had chicken-pox, and a few weeks
previously to that his mother had what he now knew to have been herpes
ophthalmicus.

Mr. Frank Juler, F.R.C.S., showed a Case of Cicatrization of the
Retina.

Intracranial Tumour causing Quadrantic Hemiopia.

By Rosa Ford, M.B.

The patient, a female, aged 35, was first seen on October 17, 1922, on
account of “ muddled ” vision for six weeks and headache. There was one
haemorrhage on the disc in the right eye, and the edge of the left disc was
blurred. Papilloedema of both discs shortly developed. There was only some
general contraction of the fields for white, but the colour fields showed right
quadrantic hemiopia. Later, the fields for white also showed this. The macula
was spared (for white and red). Vision f both eyes. There were slight coarse
nystagmoid movements on looking to the extreme right. The Wassermann
was negative both for the blood and the cerebro-spinal fluid. There was no
history of any injury to the head. In February, 1923, the papilloedema
became more marked, especially in the right eye. Vision : Right, tV ; left, f ;

Section of Ophthalmology

aod attacks of “ feeling fainfc ” were frequent. She was therefore transferred
to the care of Mr. Percy Sargent, who admitted her into the National
Hospital, Queen Square, with a view to operation. There has been no
vomiting throughout, and headache has not lately been particularly marked,
except at times. No other definite localizing signs developed, and there were
no evidences of disturbance in the pituitary region or of word or mind
blindness.

Later Note, —Mr. Sargent operated on March 2, 1923, and removed an
endothelioma, about the size of a hen’s egg, which was attached to the falx
cerebri and pressing into the left occipital lobe. The patient has made an
excellent recovery.

Mr. J. B. Lawford, F.R.C.S., and Mr. H. Neame, F.R.C.S., showed a
specimen of Bilateral Tuberculosis of Choroid with Detachment of Retina, in
a Kitten.

[This communication will be published in the British Journal of
Ophthalmology.]

Case of Subhyaloid Haemorrhage in a Girl.

By M. S. Mayou, F.R.C.S.

(Demonstrated by his house surgeon.)

Discussed by Mr. A. L. Whitehead (President) and by Mr. Ransom Pickard.

Two Cases of Primary Band-shaped Opacity of both Corneas,

By A. C. Hudson, F.R.C.S.

Case I—E. R., aged 78, coach painter, until twenty years ago; had lead
colic thirty years ago. August 22, 1922: Right vifeion, A; left vision, less
than A Vision defective in the left eye three and a half, in the right eye one
and a half years. August 30, 1922: Opacity scraped from left cornea.
December 6, 1922: Opacity scraped from right cornea. At present: Right
vision, I left vision, jV partly.

Case II. —H. Z., aged 64. No illnesses except rheumatic fever twenty-five
years ago. Sight of each eye failing two years. Band-shaped opacity in
cornea of each eye. Thin horizontal brown line in opacity in left eye. Right
vision, A; left vision, A partly.

These cases are of special interest on account of the rarity of the condition.
As far as I know, no satisfactory explanation of its causation has been given ;
and in neither of these cases is there anything pointing to the cause.

Points of practical interest arise in regard to operation and its results. In
one of the patients I operated by scraping away the film, and the result was
very satisfactory. The sight in the left eye, which before operation was less
than A, is now A in part. The eyes stood the operation very well; there was
practically no reaction. The instrument I found most satisfactory for removing
the film was the ordinary sharp corneal spud. It was difficult to make a start,
as at first the instrument skated over the rigid surface of the opacity ; but when
the film had been perforated it could be removed fairly easily, without much
damage to the underlying partB.

Hudson—Williamson-Noble

The main constituent of the opacity was examined in the clinical
laboratory of St. Thomas’s Hospital, and no definite decision as to its nature
was reached except that it was not definitely calcareous. I received the
impression that the opacity was in Bowman’s membrane.

DISCUSSION.

Mr. Leslie Paton said that Mr. Hudson’s remarks largely bore out his own
experience in a similar case, namely, the very tolerant way in which these patients
bore scraping. An old gentleman, of whose case he had experience, was remarkably
intolerant of atropine, and he had band-shaped opacities. Fortunately they did not
obstruct the pupils, and he had 5 vision in each eye. The only reason he (Mr. Paton)
had for scraping him was, that periodically a calcareous nodule formed in the opacity,
in one eye only. This acted like a grit, and the patient came with his eye streaming
with water. After each scraping the cornea healed in twenty-four to forty-eight hours,
and there was left a clean bright piece of cornea. At the end of six scrapings, there
were areas of perfectly clear cornea scattered over the band of opacity.

Mr. A. L. WHITEHEAD (President) said that in the second case the opacity
seemed to him to be of a much deeper and more infiltrating character than the other,
and he wondered whether that case would lend itself so well to scraping as the
other. It seemed almost certain that Bowman’s membrane was involved. It w'as
well worth while to try scraping.

Mr. AFFLECK Gheeves said he had a similar case to that just related by Mr.
Paton, that of an old lady aged 80, who had a corneal opacity in both eyes, below the
centre. Periodically the opacity in one eye automatically broke up into separate
spicules. She then suffered most intense pain, which was completely relieved by
scraping the surface. But the opaque surface layer gradually formed again over the
area which was left clear by the scraping. Vision was good in both eyes, because
the opacities were situated below the centres of the come®.

Atrophic Patches at the Macula; ? Tuberculous; ? Cyst.
By F. A. Williamson-Noble, F.R.C.S.

PATIENT, a married woman, aged 36, came to St. Mary’s Hospital with a
long history of various operations for tuberculous disease. She noticed that
vision in the left eye had been getting bad since 1920, and it is now less than
inj; in the other eye also the vision is now as bad. In the right eye (see figure, p. 33)
one can see the internal limiting membrane pushed forward 3d. Evidence of
that is, that vessels can be traced coming from the disc; one can follow the
vessel with the ophthalmoscope and get the parallax on it, showing it is in
front of the rest of the fundus. There are also fine lines which suggest that
there are a few wrinkles in the internal limiting membrane. In the lowest
part of the patch there is an impairment suggesting that there is a hole in the
membrane, but we were not certain of the existence of such a hole.

DISCUSSION.

Mr. LESLIE Paton said he could not offer an explanation of the appearance pre¬
sented in this case. As had been suggested, it might be a thin-walled cyst in that
area. He (Mr. Paton) thought the fibres of Mttller had been ruptured and the membrana
limitans interna lifted forward. He had specimens showing such an action in
the course of papilloedema. In effect, of course, that would be a cyst in the substance
of the retina.

Section of Ophthalmology

Mr. R. Affleck GREEVES said he made the suggestion referred to by Mr. Paton
because he had seen appearances in sections suggesting this condition, viz., large cysts
at the macula, which had apparently begun to form in the outer molecular layer, and
which seemed to have become distended, and had caused thinning of the elements of
the retina. The walls of the cysts consisted of neuroglia.

Mr. Frank Juler said the curious membrane on the front of the retina might be
a new membrane; it was a fairly common event to see a new membrane in
degenerate eyes, microscopically, probably of endothelial origin, in the neighbourhood
of the disc.

Mr. COLLEY showed the following Series of Cases illustrating various
Congenital Defects: (l) Coloboma of Lens, (2) Coloboma of Iris, (3) Coloboma
of Choroid, (4) Persistent Pupillary Membrane, (5) Coloboma of Disc, with
Maculo-choroidal Changes, (6) Coloboma of Iris, (7) Persistent Pupillary
Membrane, (8) Hyaloid Bodies on Optic Disc, (9) Microphthalmos.

Mr. Baranoff showed cases illustrating Eye Injuries.

Section of ©pbtbalmoloas.

President—Mr. A. L. Whitehead, M.B.

Mr. Cyril Walker, F.R.C.S., showed a Case of Spring Catarrh.

Tumours of Optic Nerve.

By Humphrey Neame, F.R.C.S.

Two cases of optic nerve tumour (the first in a boy aged 14, the second in
a woman aged 79) were described and illustrations shown. 1

DISCUSSION.

Mr. E. Treacher Collins said a number of points arose in connexion with this
subject which were of great interest, in diagnosis, treatment, and pathology. Many of
them had been dealt with by the author. With regard to diagnosis, he (Mr. Treacher
Collins) had found a helpful sign in the progressive character of the hypermetropia. As
the growth increased in size, more pressure was exerted on the back of the globe, and
the hypermetropia increased correspondingly. With regard to treatment, he had
removed such a growth by Kronlein’s method, and had thus saved the eyeball. He
considered it necessary to stitch the lids together at the time of the operation, as
anaesthesia of the globe persisted for some time after, and ulceration might take place.
The tumour, in the case he operated on, was cut across at the back of the eyeball at
the optic foramen ; at the latter spot the optic nerve was much enlarged, and patho¬
logical examination showed that the growth extended back through the optic foramen
into the skull. No cerebral symptoms ensued, however, and the child lived many years
afterwards, this showing that these tumours were not very malignant. He did not think
he would do the Kronlein operation in future cases, but would operate as Mr. Neame
had done in this case, by cutting the outer canthus. This allowed a sufficiently wide
field for exploration ; a finger could easily be inserted and any tumour felt at the
back of the orbit. After such an operation, there was much less disfigurement than
after a Kronlein’s operation. Knowledge as to the pathology of these tumours had
much advanced. Formerly, the names used for the different forms of growth were
very confusing: they were spoken of as myxomata, myxo-sarcomata, or myxo-
gliomata. Yet the fluid from the cysts did not contain mucin, as Mr. Neame had
remarked.

1 The subject matter of this paper is incorporated in an article with illustrations and references
published in the British Journal of Ophthalmology , May, 1923, p. 209.

[March 9, 1923.

Section of Ophthalmology

Mr. Neame had shown that evening slides of two varieties of growth: gliomatosis
and endothelioma. There was also a third variety, which was mentioned in Mr.
Hudson's paper—neuro-fibroma. 1 This last he (Mr. Treacher Collins) would have
thought was more common than Mr. Hudson's paper seemed to show. Three sorts
of tumour arose in the optic nerve because there were three different tissues from
which growths might arise: endothelium in the arachnoid membrane, fibrous tissue
in the sheaths and trabeculee, and glial tissue supporting the nerve fibres. The glial
tissue being a portion of the primary optic vesicles, gliomatous growths were neuro-
epiblastic growths. Therefore one would expect that the clinical history of such
growths would be of a different character from that of growths which began in the
fibrous tissue, or in the endothelium, which were mesoblastic.

Sir John Parsons asked how these cases compared with glioma of the brain, sup¬
posing them to be cases of true gliomatosis. They should be parallel with them, i.e.,
decidedly more frequent in the young, as borne out in glioma of the brain. What Mr.
Collins had just suggested was, that a certain proportion of those called glioma were
fibromatosis. He (Sir John Parsons) believed that was the view which Byers put
forward in his paper on “Intradural Tumours of the Optic Nerve."* He (Sir John
Parsons) objected to the term “ neurofibromatosis ” as applied to these cases,
because it implied an association with peripheral nerves. Fibromatosis was a
better term.

Dr. James Taylor said he thought glioma of the brain was common in adults,
rare in children.

Mr. M. S. Mayou said he had had a case of what used to be called neurofibro¬
matosis of the nerve, and he thought the microscopical appearance of these tumours
was largely determined by the respective predominance of fibrous structure or glial
structure ; he doubted whether the two classes could be separated. He regarded them
as hypertrophy of all kinds of tissue comprising the nerve sheath.

Mr. Humphrey Neame (in reply) said he did sew the boy’s lids together, but the
swelling in the orbit, presumably from hfemorrhage, was so great that the stitches
cut through on the fourth day. Fresh sutures held the lids together a week, and that
probably did much good in saving the eye, because there was some corneal ulceration,
as evidenced by the nebulae now to be seen. With regard to gliomatosis and these*
tumours of the central nervous system, the age differed, but the histological appearance
showed a striking similarity in the arrangement of the transverse glial fibres, just where
the nerve was swelling out and becoming widened. The transverse arrangement of the
glial fibres was similar to that in glioma of the cord, close to the strands of fibrous
tissue, and near blood-vessels.

Endothelioma of the Orbit.

By F. A. Williamson-Noble, F.R.C.S.

(ABSTRACT.)

[This paper is printed in full in the British Journal of Ophthalmology , May, 1923, p. 222.]

Case I.—Sections of growth showed a very marked tendency to the
formation of whorls. The larger ones consisted entirely of fibrous’tissue,

i A. C. Hudson, “ Primary Tumours of the Optic Nerve,” Boy. Lotul. Ophth. Bepts 1912, xviii,
p. 339.

- “ Studies from the Royal Victoria Hospital, Montreal,” 1901,

Williamson-Noble: Endothelioma of the Orbit

in the smaller the constituent cells could be seen. The growth was of a
scirrhous character and closely resembled the type of endothelioma shown by
Mr. Mayou to arise from the endothelial lining of blood-vessels rather than from
that of lymphatics. It occupied the orbit and caused proptosis and limitation of
movement of the eye. The optic nerve showed vacuolation and oedema of the
nerve head as a result of the pressure. At operation the growth was thought
to be continuous through the sphenoidal fissure with the contents of the
cranium. A dermoid was present in the ocular conjunctiva on the nasal side
at the site of an old tenotomy wound.

Case II.—A tumour occupying the orbit, causing proptosis, limitation of
movement and papilloedema. Sections showed that it contained cartilage, bone
and fibrous tissue, and that it was permeated by a large number of endothelial
cells which showed a marked tendency to the formation of blood spaces. The
patient, a boy, aged Si, died a few months after the operation, with signs
suggesting the presence of an intracranial growth. Permission for an autopsy
could not be obtained.

Both these cases were under Mr. Levy and the author is indebted to him
for his permission to refer to them.

DISCUSSION.

Mr. A. Levy said Mr. Williamson-Noble had stated the most important facts in the
history of the case. The patient in the second case referred to lived six months after
the operation, and then the death was due to intracranial extension of the original
growth. As no post-mortem examination had been allowed, nothing could be said about
the site of origin of the growth. From the appearance, he thought it seemed more likely
that it had extended backward from the orbit, and its nature, he thought, was
endothelioma.

Mr. M. S. MAYOU said endotheliomata of the orbit were very interesting growths.
He had had two such cases. 1 The first was in a child, who was admitted to Paddington
Green Hospital with proptosis on one side, and a swelling in the temporal region of the
same side. The surgeon, thinking the temporal swelling was an abscess, opened it,
and a considerable quantity of soft grumous material came away. He (Mr. Mayou)
was called in to see the case, and he said he thought there was a tumour behind the eye.
The eye became so badly proptosed that it had to be removed. The tumour consisted
of very large cells, packed together, with practically no fibrous tissue at all. The child
died within a month or two, while in the hospital. The tumour was a large
endothelioma, which had probably started in the orbit. It filled the whole middle
fossa of the skull, perforating the skull through the temporal bone, and bulging outside
in the temporal region. It was of extraordinarily rapid growth. The next case of the
kind he had had was in a girl aged about 21. She had proptosis, and an intra-orbital
tumour was diagnosed. He first removed the tumour, which was attached to the
periosteum, because he could not get permission to remove the eye. Subsequently
the orbit was cleared out. The section was very similar to that of one of Mr.
Williamson-Noblc’s cases; superficially it resembled scirrhus of the breast: large cells,
with much fibrous tissue between. The patient lived eighteen months. No recurrence
took place in the orbit, but there was an intracranial recurrence, which the physician
who saw* her said was situated in the frontal region; therefore it probably occurred
on the other side of the periosteum of the bone. Endotheliomata presented a great
variety of appearances, largely on account of the varying amount of interstitial tissue.

1 Trans. Ophth. Soc. U.K ., 1919, xxxix, p. 135.

Section of Ophthalmology 37

because of the degeneration so liable to take place in them. Clinically, they all seemed
to be very malignant.

Mr. R. Affleck Greeves said he would regard the tumour in the second case as
a mixed tumour, rather than an endothelioma. Mixed tumours contained cartilage,
bone, and not infrequently epithelial structures. He had seen a mixed tumour which
contained not only cartilage and bone, but also epithelial tubules and unmistakeable
prickle cells and cell-nests. In the orbit these tumours mostly arose from the
neighbourhood of the lacrymal gland, but not from the gland itself, though sometimes
the lacrymal gland was stretched over the tumour.

Mr. Treacher COLLINS agreed with Mr. Greeves that these tumours arose in the
neighbourhood of the lacrymal gland. They were analogous to those met with in
connexion with the parotid gland—tumours containing bone, cartilage, or endothelial
cells. It was better to call them mixed growths of mesoblastic tissue which had
reached different degrees of development.

Mr. Bernard Cridland referred to the case of a patient who came to him some
years ago, a young man who had shown very marked proptosis. As he did not feel equal
himself to proceeding very far with the operation which might be needed, he handed the
case to one of the general surgeons of the hospital who had the same feeling of hesitation
with respect to operating. The case was then sent to the late Sir Victor Horsley, who
performed an extensive operation, and found an intracranial endothelioma which had
entered the orbit through the sphenoidal fissure. A not unimportant point in this
connexion was as to how far an ophthalmic surgeon should be prepared to go in
operating on these cases. He (Mr. Cridland) considered that unless an ophthalmic
surgeon was prepared, if need be, to carry out an extensive operation, sometimes intra¬
cranial, it was far better to hand such a case over to a general surgeon. This patient
lived for about six months after the operation, as a result of which the sight of the eye
was destroyed. The vision of the other eye which was previously equal only to hand
movements owing to amblyopia from squint, improved to T \ and J. 4 , enabling him
to carry on his work as a clerk for some weeks. The patient’s age was about 22. He
mentioned this point, although it was only a side issue, as showing the visual improve¬
ment that might occur in an eye amblyopic from squint even at the age given.

Mr. Leslie Paton said that there was a point in the clinical history of these cases
which had not been brought out in this discussion. It occurred in a case in w r hich he
was interested, which he had shown at the Ophthalmological Society eighteen years
ago, that of a woman with endothelioma of the orbit starting on the inner side, close to
the lacrymal bone. 1 The nature of the tumour was a subject of prolonged discussion
among pathologists of London, and the consensus of opinion was that it was endothe¬
lioma. It was a very large growth, and getting it away involved removal of the eye.
Before the eye was removed, there was involvement of glands, first the submaxillary
gland, and that was removed at the same time as a portion of the orbital growth was
taken for examination. The nature was the same in both cases. Then the glands
down the anterior border of the sternomastoid became involved; then a growth
appeared on the top of the clavicle, and later, one in the axilla. These were removed
in turn, and proved to be of a similar nature to the primary growth. Five years after
the original growth in the orbit the woman died with a huge mass of mediastinal
glands, and the growth there was of the same nature. It was a case of transference
of growth along the lymphatics, not by the blood stream.

Mr. A. L. Whitehead (President) said that last week he operated upon a case—the
specimen of which he now showed—which, from the character of the proptosis and the
general appearance of the case, he diagnosed as tumour of the optic nerve. The eye
was blind, the growth was considerable, and there was some corneal ulceration, there¬
fore he removed the eye in order to get the growth away. Behind the eye he found a

1 Trans. Ophth. Soc. Lond 1906, xxv, p. 240.

Williamson-Noble: Endothelioma of the Orbit

series of three olive-shaped bodies, and on examining the complete mass after removal
it was found that the optic nerve itself was not involved, but was pushed on one side.
Neither was its sheath implicated. He considered it to be a neuroma, probably of the
ciliary nerve. With regard to the nature of the specimen, Mr. Mayou thought it was
possibly endothelioma of the kind which had been described.

Section of ©pbtbalmoloas.

President—Mr. A. L. Whitehead, M.B.

Case of Progressive Macular Changes associated with

Tremors.

By H. M. Joseph, M.C., M.B.

Patient, a female, aged 34, by occupation a clerk. Duration of disease,
two and a half years. History: Two and a half years ago, tremor of right
hand; no defect of vision noticed by the patient. Two years ago eyes
examined for first time. Several light spots about both maculsB. Corrected
vision, with sph. — 1*5 in each eye, tV Since then the number of spots has
greatly increased, and they are lighter than when first seen. Meanwhile the
vision has fallen to tf, and the tremor has become more marked and extensive.
Wassermann reaction negative (fig. 1).

DISCUSSION.

Mr. Rayner Batten said that Mr. Joseph’s case was of considerable importance as
it might be the adult form of cerebro-macular disease. There was a symmetrical change
of an unusual character at the macula, associated with evidences of disease of the
central nervous system. The difficulty was to classify it. He had long been trying
to establish some classification of the various (protean) forms of central choroid¬
itis or choroido-retinitis, and he endeavoured to classify them into (1) cardio-vascular:
(a) toxic; ib) arterio-sclerotic; (2) syphilitic; (3) septic; ( 4 ) degenerative. Mr. Joseph’s
case did not appear to fit into any of these. There remained therefore the cerebro-
macular class. In this class the changes would appear to vary in the different ages at
which they occurred, probably varying with the different stages of development of the
central nervous system and also with the development of the macula. The early stages
of macular disease were extremely liable to be overlooked even where there was defect
of vision to draw attention to them.

(Edema would appear to be the early stage of nearly all forms of primary macular
disease. A diffuse oedema was extremely difficult to recognize. The only thing that
could be said was that the macular area could not be seen or focussed. Then as the
cedema subsided the various forms of definite macular change developed. He (Mr.
Rayner Batten) found it extremely difficult to measure low degrees of swelling at the
macula; there was nothing definite to focus. Also the changes might be at different
levels, and this might account for the way in which changes would gradually emerge
and come into view while one looked at a macula. It was as if a fine veil had been
drawn away, and changes which had been invisible at first sight became clear to the
investigator upon prolonged and closer inspection. He thought there was still some
swelling or oedema in Mr. Joseph’s case and that this had not reached its final stage.
While the connecting link between cerebral and macular disease—whatever that might
be—remained the same in all classes, it was conceivable that the same toxin might be at

S—Op 1 * [June 8, 1923.

Joseph: Progressive Macular Changes

HAMBLIN

FlG. 1.—Drawing of left macula of Mr. Joseph’s case: right eye showed a siinilai

condition.

Hamblin

FlG. 2.—Drawing of left macula, shown by Mr. Batten, as a possible adult cerebro
macular degeneration, for comparison with Mr. Joseph’s case.

Section of Ophthalmology

Fig. 3.—Drawing of left macula, shown by Mr. Batten, as a case of senile cerebro-

macular degeneration (?).

Fig. 4.—Drawing of right macula: senile cerebro-macular degeneration (?).i

i The drawing of this case is not distinct, but it illustrates the main features.—R. B.

Joseph: Progressive Macular Changes

work, producing different symptoms at different ages. At present they had the well-
recognized infantile and juvenile types of cerebro-macular diseases, and he had suggested
a senile type (figs. 3, 4); but as far as he knew there was no description of an adult
type, and he suggested that Mr. Joseph’s case might be the missing link, i.e., adult
•cerebro-macular disease.

The points in favour of Mr. Joseph’s case being a cerebro-macular disease were:
(1) The extraordinary symmetry of the disease in the two eyes; (2) its onset at the
time of the tremors; (8) the amount of fundus change being in excess of the defect of
vision; and (4) the peculiar brown pigment.

He had found amongst his cases two others which had points of resemblance in the
•condition of the macula. The first was that of a man, aged 85, with peculiar oscillating
pupils, a fine degree of diplopia, especially with near work, and progressive macular changes
(fig. 2) ; the second, that of a woman, aged 45, with facial paralysis, in whom failure
of vision had come on simultaneously with the attack of facial paralysis. It remained
to be seen whether the course of these two cases would support or disprove his theory. 1

Mr. F. A. JuLER said he would like, in the absence of Mr. Leslie Paton, and in
connexion with Mr. Batten’s cases, to relate a case which Mr. Paton kindly allowed
him to see at the National Hospital last month. A boy, aged 18, was brought to
Mr. Paton, who diagnosed cerebro-macular degeneration. He heard that there
were other children, and asked that they might come to see him. One girl, aged 12,
was brought up and was taken into hospital. She had definite cerebral changes.
She was mentally deficient, and also showed interesting signs at the maculse; these
consisted of an area of greyness round the macula, with a definite spot at the fovea,
not so marked as in amaurotic family idiocy, but suggesting that type. Mr. Paton
thought it was really a connecting link between amaurotic family idiocy and the later
cases of cerebro-macular degeneration.

Dr. Gordon Holmes (in answer to the President’s invitation) said he could throw*
very little light on the condition. He was asked by Mr. Hine to see this case a year
ago. At that time the patient had a tremor, very similar to that seen on the present
occasion. It was then, as now*, more marked on the right side than in the left arm.
They had become familiar with this type of tremor since the epidemics of lethargic
•encephalitis. He did not mean to say the condition presented by this patient was a
sequel to lethargic encephalitis, but that the localization of the lesions of the brain
must coincide more or less with those responsible for post-encephalitic tremor. Its
chief characteristics w'ere that it came on wdien any part of the limbs was not fully
supported, persisted during movement, but could for a moment be controlled by volition.
In cases with much tremor after lethargic encephalitis the most important pathological
lesions were found in the substantia nigra and the neighbouring mesencephalic nuclei.
The slow progress of the symptoms in this case suggested that there was a primary
degeneration of certain portions of the grey matter of the brain, involving certain
mesencephalic centres. He did not remember having seen a case quite like this before;
it was unlike the other instances of so-called cerebro-macular degeneration, at least as
far as the other nervous symptoms w*ere concerned. On the other hand, it could be
safely assumed that, as in that disease, there was in this case a widespread degeneration
of nerve cells, involving the retinal elements as well as those of the brain.

Mr. A. L. Whitehead (President) said it was interesting, in association with
Dr. Gordon Holmes’ remarks, that he (the speaker) was not conscious, in the various
cases of encephalitis lethargica he had seen, of having noted any fundus changes, an
experience which he believed to be a common one. If the basal ganglia w*ere affected
in lethargic encephalitis without fundus changes, it would be a point against the basal
ganglia being affected in these cases of Mr. Joseph.

i Mr. Rayner Batten exhibited a number of drawings of the macula illustrating cerebro-
macular degeneration at different ages, and amongst them the drawings (figs. 3, 4) must-rating
senile cerebro-macular degeneration. Srr also Trans. Ophth. Soc. U.K ., 1922, xiii, p. 109.

Section of Ophthalmology

Familial Nodular and Reticular Keratitis.
By Montague L. Hine, M.D.

The cases of nodular and reticular keratitis reported in this country are
not very numerous, and the family I am able to show this evening may help to
demonstrate the close connexion between the two conditions, which, at first
sight, dealing with individual cases, does not appear so obvious.

In 1904 Holmes Spicer showed a case before the Ophtbalmological Society,
of nodular opacity in a woman, aged 23, in whom there was an increasing
defect of vision, whose father showed very similar changes, while there was a
history of similar defect in her paternal aunt and uncle. The next year
Hancock showed a case in which mother and child were affected, and noted
that the child showed many more small ring-like opacities in the corneae than
the mother, in whom nodules and larger masses formed by the coalescence of
nodules were a more marked feature. The same year the late Mr. R. W. Doyne
showed a child, in whom, close under the corneal epithelium, there were a
number of tiny milky spots, in places tending to coalesce, regarding it as a case
of this affection, and in 1914 Moxon showed two children, sisters, with an
exactly similar condition, before this Section.

In 1905 Doyne and Stephenson, in reporting five cases of familial degenera¬
tion of the cornea, definitely progressive, and more severe than any of the
above, summarized all the literature of the condition up to that date, grouping
many apparently dissimilar cases under the same head, while in his famous
Bowman Lecture in 1908, Mr. Nettleship gave the pedigrees of all the reported
familial cases in full.

Case I.—Mrs. B., aged 36, gives a history that her eyes have worried her
since infancy. She had not had them examined before she came to the Miller
General Hospital in February last, to be “ tested for glasses.” Right vision

n, with ^ 0 . 5 90°-= T 6 ff . Left vision i\, with On examination

with a corneal loupe the central area of the cornea is seen to be studded with
numerous, rather close-set, greyish-white opacities, some rather denser than
others, some in the form of rings, others nodular, while in places the nodules
become confluent (fig. l). There is not the same general diffuse haze which
was noted in Hancock’s case. The periphery of the cornea is clear in each
eye. There is no evidence of previous inflammation of the corneae, or of the

eye, and both corneae are very similar.

Case II.—G. B., boy, aged 14, gives a
aches and intolerance of light since infancy.

history of severe head-
He had not had his

eyes examined before I requested his mother to let me see the whole
family. Right vision £, with + 2'5D. sph. - 5 n. Left vision T *, with

o-7od 5 c D y] S ax. 9 o n = v- His corneae show very similar changes to those seen in
his mother, but the rings are more numerous and the nodules fewer (tig. 1), The
apparently clear cornea between the nodules shows some almost invisible
greyish specks under the epithelium, which extend beyond the area of the true

opacity, but do not reach the limbus. Mr. Basil Graves, who kindly examined
these patients for me with a corneal microscope, aptly describes the condition
as a fine sheeny speckling,” and suggests that the tissue may be impregnated
with a fine translucent granular deposit, which may be a crystalline material
haring a refractive index differing from that of the cornea. He also suggests

44 Hine: Familial Nodular and Reticular Keratitis

that perhaps the definite opacities may be due to a condensation of this
•deposit, as the same appearance is not seen in the mother. Both eyes show
the same changes.

Case III.—Lily B., aged 10, gives a history of slight head¬
ache, and of no special intolerance of light. Like her brother she
had not had her eyes previously examined. Right vision tV» with

Mrs. B. Fig. 1. G. B.

Fig. 2.—L. B.

i? -f- z au. spu. - . .

To-fiDTcyl. ax. 90* = Left vision 0 . The right cornea shows quite a
different appearance from that seen in her mother and brother, the opacity
being composed of a number of fine lines, many of which are seen to be
composed of a series of tiny dots, while some have larger dots interspersed in
their length (fig. 2). The lines in this case do not form a meshwork, as they do in
most of the reported cases of reticular keratitis, but remain separate and
uncrossed. One very fine line, rather fainter than the rest, and not obviously

Section of Ophthalmology

composed of dots, can be seen running upwards from the limbus below, and is
the only one that might suggest that it is an obliterated vessel, resulting from
previous inflammation.

The left cornea shows very few changes, but is especially interesting in that
it combines two of the linear opacities with several of the small rings, similar
to, though fainter than, those seen in her brother. Her corneas show the
same sheen as those of her brother.

In all these cases Mr. Basil Graves finds that, under high stereoscopic
magnification with the corneal microscope, the anterior faces of the opacities
lie in a plane which he judges to be that of Bowman’s membrane, which is
invisible. Each nodule has a slight thickness. In the mother, but not in the
children, some of the denser opacities were seen to be at deeper levels in the
corneal substance, even down to Descemet's membrane.

There is one other boy in this family, aged 12, whom I have examined, and
whose corneas are perfectly normal. There is a history of syphilis in the
maternal grandfather. The Wassermann reaction is negative in all the cases.

Mr. Humphrey Neame said Mr. Fisher had a case at Moorfields, that of a man,
aged 50, who had been attending at fairly regular intervals, and who had a similar
condition to that now described in each eye. But the particularly interesting point
about him was that in the right eye it was in the form of lines of opacity, and in the
left eye almost entirely in the form of nodules. He (Mr. Neame) examined that man
with the corneal microscope, and the lines in that case appeared to him to be mainly
about the middle depth of the substantia propria.

Mr. R. LINDSAY Rea, M.D., F.R.C.S., showed a case of “ Tuberculous
Eyelids, together with Disseminated Tubercle of the Body and Limbs.”

Some Suggestions on the Embryology of Congenital Crescents.
Shown by Ida C. Mann, M.B., B.S.

(Henry George Plimmer Fellow in Pathology.)

(ABSTRACT.)

We have for consideration a group of cases characterized by the fact that
they are congenital, stationary, not necessarily associated with any one error
of refraction, and most frequently situated below the disc. There is apparently
some factor which determines the greater proportion of inferior crescents and
this factor must be looked for in the normal development of the disc, since an
abnormality is more likely to be associated with a normally existing embryonic
structure than to arise de novo as a pure aberrance. The embryonic structure
in this case is the choroidal fissure. The presence of congenital crescents in
other situations does not detract from the fact that the choroidal fissure is the
determining factor in the inferior type. The presence of the fissure will
merely account for the preponderance of this type, since the essential condition
for the formation of a crescent is that the pigmented outer layer of the optic
cup should not reach quite up to the insertion of the optic stalk. The presence
of the fissure merely allows of this occurring more easily below the disc than
elsewhere.

The slides exhibited show the structure of the inferior crescent in the
human eye and also illustrate the development of the fissural region in the

Mann: Embryology of Congenital Crescents

human subject, the bird and the reptile. In the inferior crescent it can be
seen that the essential difference from the normal consists of the failure
of the pigment epithelium and nuclear layers of the retina to reach the edge of
the optic disc in its lower part. There is therefore a small area below the disc
in which all the elements of the retina, except the nerve fibre layer, are absent,
so that this layer is separated from the sclerotic only by a very thin extension
of the choroid. Developmentally, it has been shown that eversion of the
unpigmented layer of the optic cup normally takes place in the upper end of
the choroidal fissure. This is seen in a large number of vertebrates. In some
animals, including man, the small everted portion of the inner layer loses its
connexion with the rest of the inner layer and disappears, but in some other
types (birds) the connexion is retained and nerve fibres grow into the everted
projection. If in man the everted portion developed aberrantly and retained
its connexion with the inner layer, a condition resembling that normally
present in birds might result. Such a condition is present in a congenital
inferior crescent, which bears a great resemblance to the structure of the
lower part of the disc of the normal bird.

The occurrence of crescents in situations other than inferior—i.e., the failure
of the pigment epithelium to reach the edge of the disc—is comprehensible in
the light of the work of the late George Coats, who showed that any one part
of the optic cup may differentiate into tissue resembling that normally derived
from another part. The failure of the choroid and occasional thinning of the
sclera in the crescent has its parallel in normal development. The mesoderm
in contact with the outer layer of the optic cup differentiates into choroid,
while that in contact with the inner layer—whether inside the cup or everted
along the fissure—does not. The scleral condensation in its turn follows the
developing choroid.

To sum up, therefore, we may say that congenital crescents in any situation
are due to the failure of the pigment epithelium to reach the site of implant¬
ation of the optic stalk. This failure may occur anywhere, since aberrant
differentiation of the various parts of the secondary optic vesicle is known
to occur. It is, however, much more likely to occur below the disc than
elsewhere, since it is normal here at one stage of development in man.
Hence the greater frequency of inferior crescents, which can be looked on
as developmentally homologous with the cauda of birds, the architectural
basis of the caiula being present, though small, in the normal human
embryo. The failure of the choroid is directly correlated with the absence
of the pigmented epithelium, and the occasional failure of the sclera has
its parallel in the retardation of condensation along the fissure during
development.

DISCUSSION.

Sir William Lister said that the subject of the paper had been treated in a very
interesting way, but he pointed out that the author did not offer any explanation
why inferior crescents were always associated with an inferior staphyloma. He
thought that it was a generally accepted view that the inferior staphyloma was
due to weakness and giving way of the sclerotic in the region of the choroidal cleft.
Inferior staphyloma was characterized by an increased myopia in this region, with
thinning of the retinal pigment, which led to a greater visibility of the choroidal vessels
over this area. With these changes was associated the inferior crescent together with
a downward tilting of the disc. He thought that the tilting of the disc and the inferior
crescent were both due to the stretching of the sclerotic below the disc, which caused
a dragging downwards of the retina, choroid and optic disc in this direction, and

Section of Ophthalmology

therefore that the inferior crescent should be looked upon as a true “ retraction
crescent,” viz., a crescentic exposure of the sclerotic or nerve sheath by a retraction of
the retina and choroid from the disc margin. He believed that in the same manner the
ordinary external myopic crescent was due to stretching at the posterior pole of the eye,
the internal crescent to a nasal staphyloma and the so-called “ ring crescent ” to
stretching taking place in the sclerotic round the disc. Retraction of the retina and
choroid from the margin of the disc seemed to him the only reasonable explanation
for the perfectly crescentic margin of the defect, a regularity of outline which would
not be expected if the crescent were due to a local failure in development of pigment
in the outer layer of the secondary optic vesicle.

Sir John Parsons said that his view on the matter differed from that just expressed
by Sir William Lister; he thought the mode of production was that suggested by
Miss Mann. But in many cases there was associated with it some failure of the
choroidal fissure to close, and that accounted for the ectasia. With regard to the
myopic so-called retraction crescent he had long thought it was probably an atypical
coloboma—a crescent in an unusual situation, and that it had no relation to a stretching
of the walls of the globe associated with myopia. Of course it was necessary to explain
why it was so frequently present in myopia, and that, he confessed, was a difficulty.
But, having a myopic crescent as, probably, an atypical type of inferior crescent, then
with the stretching of excessive myopia, there might be an increase in the crescent due
to the stretching process. But the fact that one met with high degrees of myopia with
no crescent, and low degrees of myopia with a considerable crescent, and the further
fact that there was no relationship between the size of the crescent and the degree
of myopia, were strongly against the view that the primary cause was a stretching
directly due to myopia. Miss Mann’s suggestion with regard to the excessive
pigmentation in the disc was very interesting; a very good example of that was found
in a specimen which he and the late Mr. Coats examined, a unique case in which
there were several congenital malformations in the eye, associated with congenital
malformation of the brain and meningo-encephalocele. That case was described
in Brain .

Miss Mann (in reply) said that the presence of a staphyloma below the disc
associated with inferior crescent could also be explained as dependent on the retard¬
ation of the sclerotic condensation along the line of the fissure. The sclerotic there
might not be so strong as in the rest of the eye, hence the eye would tend to bulge at
any spot which was weak in association with delayed or abnormal closure in the upper
part of the fissure. She did not think that the presence of staphyloma below, in the
line of fissure, militated against the argument that the crescent was an anomaly of
development. She agreed with Sir John Parsons that myopic crescents also had
a possible congenital basis, though in them there was some pathological process
superimposed. But the progression of the sclerotic condensation from the equator
backwards might possibly account for a weakness of the whole posterior pole of the
eye in some of these cases.

The Tournay Reaction.

By Philip Doyne, F.R.C.S.

I This paper will be published in full in the British Journal of Ophthalmology.']

(ABSTRACT.)

The data for this paper were obtained by examining the eyes of forty cases
of general paralysis of the insane for this reaction. These oases were seen at
the Springfield Mental Hospital, and I must express my indebtedness to Dr.
Worth, the Superintendent of the hospital, for affording every opportunity for
®y so doing. In addition to these cases of general paralysis of the insane, in

Doyne: The Toumay Reaction

the course of routine examination of all patients at that hospital I looked for
this reaction. Toumay 1 describes the reaction as follows :—

“ When a man, whose ocular apparatus is normal, whose pupils* are equal, reacting
normally to light and accommodation, looks strangely to his right and maintains this
position, the right pupil becomes larger than the left. Thus, isocoria being the rule in
anterior fixation, anisocoria becomes the rule in lateral fixation.”

My conclusions were that this reaction in normal eyes can always be obtained,
though the ease with which it can be obtained varies from case to case. With
reference to the reaction in the cases of general paralysis of the insane, it
appeared that the reaction was not to be obtained in those eyes in which
the pupil reactions to light and accommodation were not present.

DISCUSSION.

Mr. J. Herbert Fisher repeated a suggestion which he had previously made in
private with regard to this pupillary phenomenon. The dilatation of the pupil on the
abducted side did not take place immediately the eyes were lateralized, but only after
a certain interval had elapsed. It occurred on the abducted side, possibly, he thought,
by reason of pressure exerted by the external rectus muscle, in strong contraction, upon
the ciliary ganglion. Mr. Doyne, relating his own experience, said he had had a sense
of strain during the maintenance of the extreme abduction which was necessary. The
pressure on the ciliary ganglion probably paralysed the control of that ganglion over
the pupil; therefore on that side there was a dilatation. He thought one need not go
further back than the orbit for the explanation.

Mr. Bayner Batten called attention to the unequal reaction of the pupil according
as light fell on the nasal or temporal half of the retina. Light falling on the nasal half
of the retina produced a prompt reaction, while light thrown on the temporal half gave
little or no reaction. The difference in reaction of the two halves of the retina was
extremely common but he had been unable to find any pathological significance for it.
He had no explanation to offer for this symptom, but all examinations of pupil reaction
with light from one side must take this very common but variable symptom into
consideration, to be of any value.

i Bull, de VAcad, de MM., 8 s6r., 1917, lxxvii, p. 680.

Sections of ADeMdne anO ©pbtbalmolOQi?.

JOINT MEETING.

Dr. G. Newton Pitt, President of the Section of Medicine,

in the Chair.

DISCUSSION ON “ THE SIGNIFICANCE OF THE
VASCULAR AND OTHER CHANGES IN THE
RETINA IN ARTERIO-SCLEROSIS AND RENAL
DISEASED

Dr. G. Newton Pitt (Chairman)

Said that this was a subject which interested both the ophthalmologist and
the physician, and one on which the profession had yet much to learn. He
hoped some new facts would emerge from this discussion.

There were one or two in particular upon which he would like information.
One was, what was the relation between the amount of blood urea and the
development of these retinal changes ? If any observations on a great number
of cases had been made—which he thought was doubtful—he hoped the results
would be placed before the meeting.

The other was as to the relationship of retinal changes to arterial
pressure and to arterio-sclerosis. In very many cases one could demonstrate
arterio-sclerotic changes in the retina when retinitis was not necessarily
present; and there were well marked cases of albuminuric retinitis in which
the arterio-sclerotic change was not necessarily present. There was also the
retinitis due to toxaemia which occurred during pregnancy, yet the retinitis
would clear up and get well as soon as the child was born.

These were some of the points on which, particularly, information was
desired. Also to what extent was retinitis dependent upon toxaemia, upon
arterio-sclerosis, and upon high arterial pressure respectively ?

Dr. H. Batty Shaw.

I need hardly say that the task of opening this discussion on the
significance of the vascular and other changes in the retina in arterio-sclerosis'
and renal disease is an exceedingly interesting one, because the ensuing
debate will give two branches of our profession an opportunity to consider
together the difficulties both meet with in the consideration of the above subject.

Ai — M & O 1 [Aort-Mi&cr 2S, 1922.

Batty Shaw: Arteriosclerosis and Benal Disease

My presence here is largely due to the fact that owing to the generosity of
my medical colleagues at University College Hospital I have had an oppor¬
tunity of studying the clinical aspects and the post-mortem findings in a
number of cases in whom the heart was found to be hypertrophied at the
necropsy. 1 I may say at once that when I had gathered together the facts
connected with this inquiry, and tried to fit them in with the various theories
which had been advanced in explanation of them, I became quite bewildered.
The only way in which I could explain the facts was to jettison former ex¬
planations, and look about for others. To show you how necessary this
step was, I have merely to tell you of the following occurrences: (a) Some of
the cases observed died of uraemic symptoms, and yet the kidneys did not
reveal the changes usually described in these organs in such cases ; (6) albumi¬
nuria was present in varying degrees of intensity, or was absent, and yet the
kidneys gave no uniform appearances which could lead one to say why they
were responsible for the former, or latter condition of the urine ; ( c ) changes
were met with in the retinas which in no way appeared to represent regularly
what form or what detail of structure the kidneys would reveal in those cases;
(d) some of the patients who during life presented signs of grave disorganization
of the brain, showed at post-mortem examination that the brain was, to the
naked eye, normal in appearance, and that the blood-vessels were free from
changes in the middle coat or in the intima.

One particular phenomenon present in the cases studied seemed to be directly
associated with the cardiac hypertrophy which they all presented ; this par¬
ticular phenomenon—hyperpiesis—was remarkable in one feature, viz., that it
was so variable; in the course of a few days or so it would fall from a
maximum to a minimum, not far removed from the normal; moreover the
converse would occur, and neither clinical study nor post-mortem inquiry was
able to reveal why these curious fluctuations occurred. In common with your¬
selves I had been taught to believe that this particular phenomenon was
caused by a condition of the arteries known as arterio-sclerosis, an expression
which has been used to cover an extensive field of change, but for the purposes
of the discussion to-day I propose to limit it to that change met with in the
middle coat of the arteries—the origin of which caused so much interesting
discussion years ago as to whether it was due to hypertrophy or sclerosis of
the middle coat—and to the other change due to the proliferation of the cells
of the intima. The obvious question arose, how could this physical sign—
hyperpiesis—vary so extraordinarily, and so quickly, between minimal and
maximal heights, and yet be due to such a stable condition as that which we
have called arterio-sclerosis? It was obvious that there was no such depend¬
ence. I could only explain the variability of the hyperpiesis by invoking the
presence of a variable amount of a poison in the blood which, besides pro¬
ducing many hitherto inadequately explained clinical conditions, could also
explain the changes in the middle coat of the arteries, as well as those in
the intima.

I found that the invocation of toxic agents present in the blood also enabled
me to explain away the difficulty of correlating many hitherto accepted signs
and symptoms of “ renal ” disease, when little or no actual renal disease was
present. I know for a fact that many other observers, both physicians and
ophthalmic surgeons, would also wish to turn their eyes away from the view
that arterial change is responsible for so much of what interests us in this

1 “ Hyperpiesia and Hyperpiesis (Hypertension),” Oxford Medical Publications, 1922.

Sections of Medicine and Ophthalmology 3

discussion, and would rather look upon the change in the arteries as being a
mere result of a toxaemia, working behind the scenes, and they have suspected
that part of this toxaemia is bacterial in origin, and thus have explained some
of those terminal episodes which present themselves to us in the form of
hemorrhages, pleurisy, pericarditis, &c.

With regard to the nomenclature of kidney disease, we know also that a
break-away has occurred from older doctrines ; too much of the change in the
kidneys seemed to be allocated to a local dyscrasia of these organs, and an
effort has been made to show that the changes in the kidneys are themselves
direct products of the toxaemia originating from bacterial action at a remote
site, or actually in the kidneys, or to a toxaemia the origin of which is at present
unknown to us, but is certainly present as judged by its effects. This tendency
towards a study of the blood has already led to a greater certitude of diagnosis
as to the condition of the kidneys than any clinical examination of the body,
or chemical study of the urine—at any rate so far as protein extrusions are
concerned. Moreover, claims have been put forward to the discovery that
changes in the arteries are due to a toxaemia of bacterial origin. We have
known for years that intimal change can be produced experimentally by the
injection of bacterial toxins, and now it has been claimed that the changes in
the middle coat are simply of the nature of a chronic inflammation. As a
physician, I feel that the time has arrived when we may safely discard the
older doctrine which makes arterio-sclerosis responsible for the signs and
symptoms we are to discuss to-day, and by concentrating our efforts upon
the toxic view and supporting it as probable, we may thereby stimulate
research which shall give this newer, or rather, revived conception, the support
of demonstration.

Turning to the studies carried out by ophthalmic surgeons, it is well known
that despite the strong views held by them that it is possible to differentiate
arterio-sclerotic retinitis from albuminuric retinitis, they find difficulties. They
admit that there is something wrong in their deductions, and we are familiar
with the fact that they would prefer to speak of renal retinitis or the retinitis
of renal disease, rather than of albuminuric retinitis, for reasons approved by
physicians; indeed, as a physician, I feel that they have relied upon my
branch of our profession too much, and have been satisfied too readily sometimes
to accept our clinical diagnosis of some vascular catastrophe which has
ended in paralysis or death. Further, they have gone so far as to admit that
an arterio-sclerotic retinitis may be succeeded or accompanied by the signs of
renal retinitis, and would argue that this is due to the fact that the harmful
effects of arterio-sclerotic changes have progressed and, by involving the
kidney, have led to the superadded changes formerly considered attributable
to kidney disorganization. Such explanation has been widely held in the past,
but as already intimated, evidence has been found which points to the possibly
minor part played by the kidneys in the production of so-called “ renal” signs
and symptoms.

Some ophthalmological experts are already prepared to concede that the
changes in the retinae in renal retinitis are toxic, and that the seat of origin of
these blood-borne toxic agents is pre-renal: so that, for them, even renal
retinitis is a misnomer, just as is its predecessor, albuminuric retinitis. There
are other weak points in the deduction made by some ophthalmic observers,
namely, some of the changes met with in arterio-sclerotic retinitis are due in
part to thickening of the middle coat, hence the silver or copper-wire appearance
°f the retinal arteries; other objective signs are due to thickening of theintima,

Batty Shaw: Arteriosclerosis and Renal Disease

hence the irregular lumina of the arteries as seen by the ophthalmoscope.
Now both of these changes indicate additions to, not subtractions from, the
strength of these vessels.

How is it that haemorrhages occur in the retina in arterio-sclerotic
retinitis ? When the haemorrhage passes off no change of the nature of a
rupture of retinal artery or vein has been demonstrated. As a physician,
I am inclined to wonder whether the haemorrhages are not more likely to be
capillary in origin, and to have a genesis similar to that met with in the
petechiae of malignant endocarditis and other infective disorders. It is true
that we have not yet arrived at a clear demonstration that these petechial
manifestations are due to ruptured capillaries ; but there is a large amount of
analogical evidence that they are capillary in site of origin, and that they are
of infective origin. Why should their genesis be different from that of the
petechiae developed elsewhere ? And how are the white patches met with in
arterio-sclerotic retinitis explained ? Where do they come from ? Or are they
formed from local elements ? If so, what provokes their formation ? Surely
not arterio-sclerotic changes ! Are they not likely to be provoked by some
similarly noxious agent, also brought by the blood stream ?

We cannot, however, disregard the fact that most painstaking studies over
very long periods have been made by ophthalmic surgeons, and a steady
progress has been observed from changes met with in the retinal arteries to
the development of haemorrhages, of white patches, and even of papilloedema,
all due to arterio-sclerosis! There can be no reason whatever to carp at these
findings, except that they need not be charged primarily to the account of the
vessels. Is it not possible that changes even in the arterial walls leading to
the thickening of the middle coat, with or without proliferative changes in the
intima, are all due to a poisonous condition of the blood? Indeed, as already
stated, one recent study has led to the deduction that the changes in the
middle coat are of a chronic inflammatory nature, implying that an infective
agency is behind them all. We also know from experimental studies already
referred to, that intimal changes can be produced by the injection of bacterial
toxins, and the study of syphilis shows incontestably what havoc can be
engendered in the arteries by spirochaetes.

It is said that renal retinitis is always bilateral, and yet works by
ophthalmic surgeons reveal the observation that “ renal ” changes may be
shown in one retina by unilateral papilloedema, which conforms with the
well-known observation that blood-poisons need not necessarily produce
symmetrical changes—unilateral Argyll-Eobertson pupil and single wrist-drop
in lead-poisoning being other examples of this anomaly. Further, I have seen
figured in one work of reference “ renal ” retinitis which had lasted six years,
though it is stated that cases of “ renal ” retinitis seldom survive two years—in
contradistinction to cases of arterio-sclerotic retinitis in which the patients
may live a great number of years: the duration of life after the development
of both forms of retinitis seems somewhat variable.

If we need further disquieting evidence as to the dependence upon
vascular disease, of haemorrhages into the retinae and the development of white
patches, we may reasonably put forward the observation of ophthalmic
surgeons that retinal haemorrhages and white patches have been noted in
pernicious anaemia, in the “fast disappearing disease” chlorosis, and even
in the secondary anaemias due to peptic ulcer or to malignant ulcer of the
stomach—diseases in which arterio-sclerosis is not charged with being the
immediate cause. We may well ask, also, what is the source in secondary

Sections of Medicine and Ophthalmology

anaemias of the development of soft-edged white patches in the retina
which are quite indistinguishable from the “ cotton-wool patches ” of renal
retinitis? Assuredly the changes in the “renal” retinitis and in the
secondary ansemias are due to noxious agencies brought by the blood.
It seems to me that it is likely that the changes met with in arterio¬
sclerotic retinitis are not due to the vascular change* but that the
haemorrhages and white patches and the slight change in the disc differ
only from those met with in “renal” retinitis in their being called into
existence by the slower operation of blood poisons, or by a decreased local
iissue-sensitiveness in the former case as compared with the latter, or by the
smaller amount of such poisons arriving at the scene of action in the former
case, as compared with the latter. Some such explanation would also account
for the longer survival of the former cases compared with the latter. It is
taught that oedema of the limbs and body is a late arrival in the cases under
consideration : possibly that is the reason why the white patches of arterio¬
sclerosis are so sharply defined and somewhat less extensive and are so
“woolly” and so voluminous in so-called renal retinitis. 1

If further evidence is needed that changes in the retina can be, and are,
produced by a disordered blood-state rather than by changes in the kidney
or by changes in the retinal vessels, we have it beautifully illustrated in
eclampsia, where changes may be met with in the eye and in no other organ,
such changes being remedied by abortion or by other evacuation of the womb.

Arterio-sclerosis has had a long innings as a cause of retinal change,
but I submit that it is more reasonable to look upon arterio-sclerosis as a first
effect, and arterio-sclerotic retinitis as a later one, of a toxaemia which acts
. slowly and in minimal quantity: when the toxaemia acts quickly or in
accumulated large bulk the other type of retinitis results, and this other type
needs another qualification than “ renal,” for the changes in the kidneys may
be minimal, or the changes may be extremely variable, or extreme changes
may be found in the kidneys with little or no change in the arteries or in the
retime. I would suggest that for the terms “ arterio-sclerotic ” retinitis and
‘albuminuric” or “renal” retinitis, or the retinitis of renal disease, we
should substitute the terms “chronic” and “acute,” “late” and “early”
or “minimal” and “maximal toxic” retinitis, leaving for the future the
investigation of the nature of the toxin concerned, the laws by which its
potency is regulated and the reason why the kidneys should be so variably
involved in different cases.

Mr. R. Foster Moore.

I propose to bring forward this evening what evidence I can in support of
the view that in some cases of arterio-sclerosis a distinctive form of retinitis
is developed, which is due, I believe, to the local vascular disease in the retina.
I need do no more than say that the term retinitis is applied in the sense in
which it is used in nephritis or diabetes.

It may be stated at the outset that these cases have usually been confused
with renal retinitis, and I believe the statement that has been made and
repeated, that renal retinitis in the old conveys a prognosis which is less
serious than in the young, is in part due to the inclusion of the cases under
consideration.

^ Sir J. Herbert Parsons, F.R.S., “ Diseases of the Eye,” 1918; R. Foster Moore, “Medical
Ophthalmology,” 1922.

Foster Moore: Arteriosclerosis and Renal Disease

An endeavour will be made to establish the three following propositions :—

(1) That the ophthalmoscopic appearances of the condition are in large
measure distinctive as compared with renal retinitis, the chief condition from
which they have to be identified.

(2) That the retinal exudates are developed as the result of the local
vascular disease in the retina.

(3) That as regards length of life and manner of death, this ophthalmoscopic
condition implies a prospect which is in sharp contrast with that conveyed by
renal retinitis.

I have collected in the table recorded (pp. 11-14) forty-seven cases of
retinitis which I have seen on several or many occasions, and w 7 hich I have
had under observation in most cases for a number of years.

Proposition 1.

It will, I believe, be agreed, that in the majority of cases of general arterio¬
sclerosis, the retinal arteries share in the disease to such a degree, that the
condition in them is recognizable on ophthalmoscopic examination. Thus,
of forty-four consecutive cases admitted to the wards of St. Bartholomew’s
Hospital on account of a gross vascular cerebral lesion, thirty-one, i.e., 70 per
cent., provided undoubted evidence of retinal vascular disease ; and we may go
further and say, that an estimate as to the degree to which the general arterial
disease has attained can be arrived at, with considerable accuracy, by the
evidence which the retinal vessels supply.

It does not come within the scope of the present communication to describe
these appearances, but as the general disease progresses, the disease in the
retinal vessels becomes more marked, until, in a certain proportion of cases,
exudates are developed in the retinal tissues, which I believe are due to the
thickening of the coats of the arteries and to the reduction in their lumina,
leading to impaired circulation in the tissues. I have elsewhere given reason
for thinking 1 that the local pressure in the retinal arteries in these cases is less
than the normal, though the pressure in the large arteries is greatly raised.

TJie Ophthalmoscopic Appearances.

It is not suggested that the individual spots or small areas of exudate, the
presence of which is taken to justify the term retinitis, are pathognomonic,
or that spots which at any rate, ophthalmoscopically, are similar do not occur
under other conditions, but it is suggested that the spots themselves are in
some measure characteristic in appearance, arrangement, and in the changes
they undergo, and that when they are present in combination with marked
vascular disease an ophthalmoscopic picture is presented which is in large
measure distinctive.

The exudate takes the form of small whitish dots, or spots, or small areas;
they have hard edges, and there is no pigmentary disturbance nor evidence of
oedema around them ; a spot of the diameter of one of the main retinal veins
would be a rather large one. They occur chiefly in the central regions and are
seldom copious ; they may take the form of a partial or complete star figure
around the yellow spot; at times they seem evidently arranged in relation to
the radicles of the veins. Occasionally larger areas or small plaques are seen,
formed apparently by the coalescence of spots which previously were discrete.

1 Trans. Ophth. Sor. C.K ., 1916, xxxvi, p. 319.

Sections of Medicine and Ophthalmology

In some cases the exudate is so scanty and the evidence of vascular disease
is so conspicuous, that the exudate is overlooked or ignored amongst the much
grosser and more obvious changes. In most cases flame-shaped retinal haemor¬
rhages are present ; they are incidental to the vascular disease and have but
little distinctive value.

A very striking feature of this form of retinitis is the frequency with which
it is unilateral; thus out of forty-five of the present cases it affected one eye
only in twenty-eight instances, i.e., it was unilateral in 60’7 per cent.; evidence
of disease of the vessels was always present in the other eye. In renal disease
retinitis may occur in one eye before it is evident in the other, but it very
seldom remains unilateral for any long period.

The exudate is slow to develop and slow to undergo change, but if an
accurate plan is made, it is easy to satisfy oneself that individual spots
disappear and leave behind no trace of their former presence, but fresh ones
are usually simultaneously appearing, so that the general aspect of the
ophthalmoscopic picture may be maintained over long periods. The longest
periods of which I have notes are seen in Cases XXXII and XLIII, in which
retinitis persisted for eight years and seven months, and seven years and nine
months, respectively. In other cases the exudate may entirely disappear;
this happened in eight of the present cases, viz., Cases XII, XXVIII, XXX,
XXXI, XXXV, XXXVIII, XLI, and XLVII.

In two of the cases disappearance of the exudate followed thrombosis of
the retinal artery and seemed to be dependent upon the thrombosis for its
occurrence, for in Case XXVIII retinitis was at first present in each eye,
thrombosis then occurred in the left retinal artery, and disappearance of the
exudate followed in this eye whilst it persisted in the other. There is good
evidence that an eye which has been the subject of serious fundus disease,
such for instance as thrombosis of the central vein or artery 7 , or previous
retinitis, or even high myopia, is as a consequence protected against the
occurrence of retinitis in renal disease, and it seems that in the above
mentioned cases another aspect of this phenomenon is exemplified, for
retinitis was at first present, and the occurrence of thrombosis of the retinal
artery' seemed to determine its disappearance.

The chief points in which the ophthalmoscopic appearances differ from
those of renal retinitis consist in the character and distribution of the exudate
and the changes it undergoes, the frequency with which it is unilateral, its
association with severe retinal vascular disease, the absence of oedema of the
retina so that retinal detachments seldom if ever occur, and the absence of
cotton*wool patches.

Finally, in this connexion, I should like to quote the following from
£be late Marcus Gunn’s original paper on the ophthalmoscopic evidences of
arterio-sclerosis, 1 in which he says:—

k In the most advanced cases the lines of the folds which radiate from the
fovea centralis, due to the oedema, are sometimes eventually marked out by the deposit
of white spots of degenerated effusion, so that wo get the ophthalmoscopic appearances
Agnostic of so-called albuminuric or renal retinitis, though in the variety now under
consideration the condition may exist only in one eye and may not be accompanied by
albuminuria.”

s This appears to be a good account of the condition we are considering;
is an account to which I had paid no attention previous to preparing this

1 Trans , Ophth . Soc t U* K., 1898, xviii, p. 361.

Foster Moore: Arteriosclerosis and Benal Disease

address. Amongst Gunn’s fourteen cases there are six to which the above
description would apply, and one may anticipate by saying that each of these
six suffered from a cerebral haemorrhage.

Histology .

These cases were followed as “out-patients,” and consequently I have once
only obtained a specimen for examination: I hesitate therefore to say much
with respect to the histological characters of the exudate. In this specimen
the spots were composed of small spherical areas of structureless hyaline
material in the external molecular layer; they were deeply stained by orcein
and took on a mauve colour in eosin and hsematoxylin sections. So far as their
structure goes they seem to be similar to the exudate which forms the “ star
figure ” in renal retinitis, they are however smaller, there is no histological
evidence of oedema, and no fat-containing phagocytic cells were present, such
as may be seen in renal cases.

Proposition 2.

That the retinal exudates are developed as the result of the local vascular
disease in the retina and indicate a further advanced stage of it. This point
can be considered in individual cases, and by a comparison of groups of cases.
It is sometimes possible to watch, in the individual, exudate becoming super-
added in the course of some years, where at first vascular disease alone was
present. Cases XXVI, XXXII, XXXIV, XXXVIII, XL, XLI, and XLIV
are examples of this.

Case XXXII is worth quoting in a little detail. The patient was first under
the care of Marcus Gunn in 1908, at which time she had extensive arterio¬
sclerosis but no retinitis, her urine was free of albumin and sugar, and this was
also true in 1909 and 1910. In 1911 she came under the care of the late George
Coats, and then for the first time was found to have what he described as
44 white glistening spots disposed radially round the macula,” and albumin in the
urine. I saw her first in 1913 when she had a blood-pressure of 250 mm., a
cloud of albumin in the urine, and retinitis in each eye ; she was under my
constant observation from this time till September 1, 1919, the date on which
I last saw her. She had had a stroke in May, 1918, her blood-pressure was
260 mm., and she still had retinitis in each eye : thus for the first three years
during which she was under observation she had retinal vascular disease only;
she then developed retinitis, and this persisted more or less unchanged for
eight years and seven months.

Again one may make a comparison between a group of patients in whom
vascular disease alone is present in the retina, and another group in whom
retinitis is present in addition. If, as I believe, the presence of exudates in the
retina implies a stage of arterio-sclerosis in advance of a case in which vascular
disease alone is evident, and if, as I am sure is the case, the disease of the
retinal vessels increases pari -piwu with the general arterial disease, then a com¬
parison of two groups of patients—in one of which vascular disease alone is
present, and in the other of which exudates are present in addition to the
vascular disease—should provide evidence that the latter group is composed of
patients suffering from a further advanced stage of the disease. For this
comparison I have available thirty-five patients belonging to the former
group, and thirty-one belonging to the latter; the average age of each
group is 59.

Sections of Medicine and Ophthalmology

The average systolic blood-pressure of those without retinitis was 211 mm.,
and of those with retinitis 222 mm.

In March, 1919, seventeen (i.e., 48 per cent.) of the former group were
known to have died, and eight were known to be alive, whilst on the same
date twenty-one (i.e., 67 per cent.) of the latter group were known to have
died, and six were known to be alive; further, on the same date, eleven of
the first group were known to have suffered from a gross vascular cerebral
lesion, and in eleven there was evidence that such had not occurred, whilst
of the second group thirteen were known to have suffered from such a lesion,
and nine had not done so.

It will be seen that, as regards the systolic blood-pressure, the incidence of
death, and the frequency of gross vascular cerebral lesions, the second group
manifests a higher grade of disease than the first. One may safely assert
that these findings are at any rate compatible with the view that it is in the
more advanced cases of arterio-sclerosis that retinitis is developed.

It is interesting to speculate, were it possible to examine the other tissues
of the body during life under a magnification of fifteen diameters, as is done
in the eye, whether changes in them would not be also found to occur,
corresponding with these changes which are visible in the retina alone of
the whole body, and especially would one expect such changes to be found in
the brain tissues, for the retina is but a specialized part of the brain which is
rendered subject to our examination.

Proposition 3.

Lastly, we come to the consideration of the length of life and the manner
of death of patients who are the subject of this form of retinitis. It is un¬
doubtedly true that few patients live so long as two years after the discovery
of renal retinitis; thus Belt 1 found that of 419 patients, 94 per cent, died
within two years, and Miles Miley 2 found in forty-five cases that the average
duration of life after the discovery of retinitis was four months, and many
other figures of a similar nature are available. We shall see that the group
of patients we are now considering contrasts sharply with the foregoing.

As regards the prospect of life, the prognosis is of course somewhat grave ;
it is, however, less grave and more uncertain than in renal cases; such a
patient may at any time develop a cerebral apoplexy, but, on the other hand,
he may live for several or many years; thus, of twenty-eight patients who were
known to have died, the average length of life after the discovery of the retinitis
was two years and eight months, 8 whereas, as stated above, the average length
of survival of the renal cases was four months only. Again, fifteen patients
out of the twenty-eight, i.e., 53 per cent., lived for more than two years,
whereas 6 per cent, only of Belt’s renal cases lived for a similar period.

Whilst the prospect of life in these cases is very uncertain it will be seen
how much better it is on the whole than in renal cases.

i \ Jtmrn. Amer. Med. Asanr., 189,5, \xv, p. 735.

- Trtms. Ophth. Soc. C.K. , 1888, viii, p. l.'M,

Or. if one takes living and fatal rases together, the average length of survival after the.
discovery of retinitis is greater than three /fears mid 6’6 months ; I say ** greater than,” for it is
rlf*ar. that as the “ at present surviving” cases die, tin* average length of survival of the group
will 1*' increased.

10 Foster Moore : Arteriosclerosis and Renal Disease

The second point under this head refers to the manner of death of these
patients. I have no precise figures, nor have I been able to find any, as to the
proportion of patients with renal retinitis who die in uraemia, but it is certainly
a considerable number. Of the present cases there are three only in which
either nephritis or uraemia is given as the cause of death. I have received
a report as to the cause of death in twenty-eight out of the thirty patients who
are known to have died. Of these twenty-eight, fourteen, i.e., exactly 50 per
cent., are known to have died of a gross vascular cerebral lesion, and in addition,
four of the seventeen who were alive when last heard of, were known to have
developed such a lesion which had not culminated fatally. I do not think it
can be doubted that the vascular lesion was the dominant lesion in these
patients, and that whilst no doubt the kidneys shared in the general
disease, their function was not sufficiently impaired by it to threaten life
seriously.

Condition of the Urine.

Having regard to the frequency with which albuminuria is intermittent in
this class of patient, and seeing that most of them were watched as out¬
patients, the most that can be said is, that in seventeen cases the urine was
albumin-free on one or more occasions. In some cases six or eight exami¬
nations were made, but in others the urine was examined once only, so that,
no doubt, had the examinations been more frequent, the number of cases in
which albumin was present intermittently would have been increased.

In conclusion I suggest that:—

(1) In a proportion of cases of general arterio-sclerosis, as the disease of
the retinal vessels increases, exudates form in the retinal tissues which are
probably dependent upon the local vascular disease.

(2) That the ophthalmoscopic appearances resulting are in considerable
measure distinctive.

(3) That the prognosis implied by this form of retinitis as to length of life,
is quite uncertain, but may extend to several or even many years, and that
it differs greatly from renal retinitis in this respect.

(4) That a large number of these patients die of a gross vascular cerebral
lesion, according to the present investigation 50 per cent., and

(5) That the condition calls for separate recognition, and that the term
“ arterio-sclerotic retinitis ” seems appropriate.

In explanation of the table of cases now following, in the second column is
given the age of the patient when he or she first came under observation. The
third column gives the systolic blood-pressure and is in most cases the average
of several readings taken at different visits. The fourth column includes some
details with regard to the retinitis. The fifth column gives the ultimate history
so far as it is known, the evidence with regard to the occurrence of cerebral
vascular lesions, and the cause of death where this is known. Cases I to
XXX are those of patients who are known to have died, and Cases XXXI
to XLVII are those of patients who were alive when the last information
with regard to them was obtained.

Sections of Medicine and Ophthalmology

.1. H.

K. G.

A. t\

M. A. W.

A. C . W.

A. C.

YII

H. C.

YII I
G. H.

IX
I. J.

.1. L.

XI
J. 1\

XII

.1-

XIII

A. S.

XIV
W. H. T

Ct H. Q.

Age | B.-P.
45 215

49 *215

56 2-13

68 255

71 230

74 173

54 *220

60 265

50 290

53 210

53 205

63 *245

63 —

66 —

67 , 240

Table of Cases.

Details of retinitis , Ultimate history

June, 1913, retinitis right Died November 11, 1913, five months after
eye only; left arteries thin the discovery of retinitis, of “cerebral

threads, no exudate hemorrhage ”

January 30, 1914, star Died November 6, 1914, ten months after

figure in right eve only ; the discovery of retinitis, of a “ cerebellar
March 25, 1914, star still cyst ” ; post mortem
present

February 13, 1913. retinitis April 4, 1914, “three slight attacks of tem-
both eyes ; November 27, porary loss of power of right arm and leg; ”

1913, retinitis increased, died November, 1915, two years and nine

star figure left eye; Jan-j months after the discovery of retinitis;

nary 15, 1914, retinitis j “a day or two before her death, which

stili present occurred suddenly, she had a hemiplegia ;

! cerebral hiemorrhage ’’

November 4, 1913, retinitis ; “ One year ago awoke and found three fingers
right eye of the right hand were funny and numbed,

she has not recovered full use of them ” ;
died November 14, 1913, ten days after
the discovery of the retinitis, of a
1 “ paralytic stroke ”

! July 14, 1913, retinitis “ Loses the use of her legs ” ; died May 29,

right eye 1916, two years and ten months after the

discovery of the retinitis, of “ interstitial
nephritis and unemia ”

December 31, 1913, retinitis Died May 7, 1914, four months after the
! right eye discovery of retinitis,“ paralysed in speech

and unconscious ”

i December 14, 1912, retinitis Died December 6, 1915, three j ears after the
I both eyes; November 8, discovery of retinitis, of “cerebral con-

1914, retinitisalmost gone gestion with symptoms of effusion ”

from both eyes with par¬
tial atrophy following

(edema of the nerve

October *20, 1913, retinitis Died August, 1914, ten months after
both eyes the discovery of retinitis, of “ cardiac

failure ’’

January. 1913, retinitis left June, 1913, “in Soho Square Hospital with
eye, with a star figure a paralytic seizure”; died January 2,

1915, one year and eleven months after the
discovery of retinitis, of “ cerebral throm¬
bosis ”

February 3, 1914, retinitis Died February, 1915, one year after the
both eves, exudate along discovery of retinitis, of “ cardiac failure ;

1 the radicles of the veins a complication of diseases”

April 30, 1913, retinitis with Died October 4, 1913, five months after the
a star figure, left eye discovery of the retinitis ; “ had a stroke,

lost all power of his left side, died within
! twenty-four hours ”

March 6, 1913, retinitis. Died April 14, 1914, one year and one month
with a star figure begin- j after the discovery of the retinitis, “in a
ning both eyes; Decern-I fit”
ber 18, 1913, thrombosis i
of artery has occurred in
right eye with disappear¬
ance of exudate; left eye
1 as before

March 4, 1915, partial star Died September, 1915, six months after the
figure in right eye discovery of the retinitis, of a “ malignant

growth of the liver ”

October 25, 1913, retinitis Died November 21, 1915, two years and one
i right eye; February 22, i month after the discovery of the retinitis,
1914, still present j of “chronic interstitial nephritis and

; ! uriemia”

February 26, 1913, retinitis 1 Died February, 1915, two years after the
right eye; September 20, f discovery of the retinitis, “ in his sleep;

! 1913, still present; March ! cardiac failure ”

j 7, 1914, still present 1

12 Foster Moore: Arteriosclerosis and Renal Disease

Table of Cases—( Continued ).

Ago ,

B.-P.

Details of retinitis

XVI

0. R.

! 71

225

February 1, 1911, retinitis j
both eyes; January 3,

1 1914, still present; Feb¬

ruary 7,1914, still present

XVII

F. B.

I 65

240

i October 21, 1913, retinitis
right eye

XVIII
E. C.

! 53

| 242

April 14, 1913, retinitis

Doth eyes ; March 12,
1914, retinitis reduced, j
both eyes j

XIX J
E. E.

1 _

March 13, 1914, retinitis
both eyes, with a partial
star figure; February 24,
1915, as before

A. A.

i 235

i September 16,1913, retinitis
| both eyes; March 3,1914, j

1 still retinitis, both eves

1 " !

XXI

J. B.

300

1 June, 1913, retinitis left
eye; November 4, 1914,
still present

XXII

J. Cl.

185

November 11, 1913, retinitis
affected eye; March 7,
1914, still present

XXIII

L. F.

237

June 12, 1912, retinitis right
eye

XXIV

A. H.

285

March, 1913, retinitis right
eye; April 23, 1914, still
present, a partial star 1
figure

XXV

E. X.

—

XXVI

C. S.

260

October 28, 1913, no re¬
tinitis ; February ‘24,1914,
retinitis, right eye

XXVII
E. F.

225

Retinitis in eye without
thrombosis only

xxvni
W. T.

220

December 30, 1912, retinitis
both eyes; April 2, 1914
(when last examined)
thrombosis of left central
artery occurred and all
exudate disappeared, still
present in right eye, in ,
which thrombosis did not
occur

XXIX

A. S.

240

August 7, 1913, retinitis
both eyes

XXX

W. (\

191

March 13, 1914, retinitis
both eyes; March 12.

Ultimate history

Died January 16, 1916, five years after the
discovery of the retinitis, of symptoms of
“ cancer of the liver ”

Died November 23, 1913, one week after the
discovery of the retinitis, of “cerebral
haemorrhage ’’; post mortem

“ Three years ago sudden attack of numb¬
ness running up both legs, went off after
three minutes”; died February, 1917,
three years and nine months after the
discovery of the retinitis, of “ symptoms
of consumption ”

Died October 14, 1915, one year and seven
months after the discovery of the retinitis,
of symptoms of “chronic renal disease
and apoplexy ”

“ Numbness in legs and thighs as if half
dead” ; died August 29, 1916, two years
and eleven months after the discovery of
the retinitis, of symptoms of “ chronic
nephritis ”

February, 1914, “had a stroke from which
she has a good deal recovered”; died
September 30, 1917, four years and three
months after the discovery of the retinitis,
“ in a stroke, totally blind ”

Thrombosis of central retinal vein ; died
March 4, 1918, four years after the onset
of retinitis, of “consumption ”

Thrombosis of a tributary of the retinal
vein ; died April, 1920, seven years and
ten months after the discovery of the
retinitis, “ of a stroke of which she had
three ”

Died January 15, 1921, seven years and
nine months after the discovery of the
retinitis, of “diabetes mellitus”

Died nine years and six months after the
discovery of retinitis, of “ angina pectoris,
no stroke ”

Died April 5, 1914, ? cause; no evidence of

)ien Anri
a stroke

1916 ;
pea red

retinitis

retinal vein ; died, date unknown,
“suffered from cerebral lnemorrhage ”
ipril 2, 1914, “no stroke, can walk three
or four miles at a good pace ” ; died
January, 1916, three years and one month
after the discovery of retinitis, cause not
known

speech unintelligible”; died December
24, 1915, one year and four months after
the discovery of the retinitis, of “ Bright’s
disease, end came quite siiddenly ”

March 12, 1916, “slight paralytic stroke all
down right side one year ago, speech
affected, laid up four months, right side
of face drawn ” ; died January 7, 1918
(? 1917), three years and ten months after
the discovery of the retinitis, “ after
another stroke within twenty-four hours ”

Sections of Medicine and Ophthalmology

Cases which were alive when the last Information was acquired with regard

TO THEM.

Age B.-P. Details of retinitis * Ultimate history

XXXI 47 | 180 i May 24, 1913, retinitis right j October 18, 1913, “suddenly taken with

A. D. | eye only, well-marked star shaking all down the right side, right foot

figure; November 15,1913, | seemed to drag and have no use in it, all
star figure much less con- right leg numbed”; November 17, 1915,

I spicuous; February 14, I “ twitchings all down right side”; July

' 1914, star figure gone ex-j 18, 1918, “acute right hemiplegia and

cept for one or two minute aphasia, blood-pressure 193 mm., urine no
dots; November 17, 1914, albumin”; February 13, 1919, “has been
star gone completely; 1 in bed ever since 1918 ”

, February 13, 1919, no star
figure and no exudate;
thrombosis has occurred ,

1 in the left central retinal

arterv

XXXII 48 215 November 28, 1908 ; “exten-! November 28,1908, first seen bv Marcus Gunn

A. H. ' sive arterio-selerosis ; no who noted extensive arterio-sclerosis, no

albumin ” (Marcus Gunn); albumin; January 28, 1911, first seen by

January 28, 1911, “gross George Coats who found retinitis and

vascular changes, white albuminuria ; since this time she has been

glistening spots disposed under my constant observation till Sep-

ntdiallvroundthemacula” tember 1, 1919; May, 1918, “stroke left
(GeorgeCoats); September side of face, left hand, and left leg;” Sep-

I 1, 1919, haemorrhages and , tember 1, 1919, “still gets about, blood-

j exudate still present in pressure now 200 mm., haunorrhages and

each eye (see text for exudate still present in each eye ”; retinitis

fuller reference, p. 8) is known to have been present for eight

years and seven months. (See text for a
fuller account, p. 8;

65 197 May 30, 1913, retinitis right Under observation for five years and six

eye months, gives a good account of a mild

stroke in 1910, and of a second in 1911 ;
June 4, 1916, “ no fresh stroke ” ; February
12, 1919, “too feeble to walk, eyes about
the same ”

60 160 June, 1913, no retinitis; March 15, 1916, “my health is better, my

August 29, 1913, star eye does not trouble me ” ; retinitis known

figure just beginning in to have been present for two years and six

the left eye; September months

16, 1913, star figure in¬
creasing

60 223 February I I, 1913, scanty February 28, 1916, “ thoroughly fit in every

exudate which completely way ” ; retinitis present three years before
disappeared last seen

67 210 October 6, 1913, retinitis March 5, 1916, “ am very well in health and

right eye; April 18, 1914, my eye improves”; January 15, 1919,
still present “general health very good, never any

stroke”; retinitis known to have been
present live years and seven months before
last report

66 175 May 20, 1913, retinitis right March 5, 1916, “still active and able to take

eye; September 2, 1913; walking exercise ami can read”; January

retinitis increased 29, 1919, “ father in very good health and

leads quite an active life, remarkably
active considering his age, 71 ” ; “ no

stroke”; retinitis present five years and
nine months before last report

55 175 February 4, 1911, no reti- April I, 1914, “no stroke, is in very good

nitis; April 5, 1913, reti- health ”; retinitis known to be present one
nitis both eyes ; October year before last report
2-7, 1913, retinitis still in
right eye ; disappeared ,
from left

65 205 Ketinitis, both eyes Not traced; June .30, 1916, “ death certificate

has not been issued” (Hcgistrar-Generalj

14 Foster Moore: Arteriosclerosis and Benal Disease

Table— ( Continued ).

Age

B.-l\

I Details of retinitis

1 Ultimate history

M. R.

137

! August, 1908, no retinitis;

1 August 31, 1921, retinitis
j both eyes

Thrombosis of venous tributary, right eye;
under observation thirteen years, developed
retinitis whilst under observation ; August
31, 1921, “no stroke, walks to hospital”’

XLI !
A.B. |

195

. May 16, 1913, no retinitis;

; March 25, 1914, retinitis

: in affected eye forming a

star figure ; September 10,

J 1921; no retinitis

Thrombosis of central retinal vein ; Septem¬
ber 21, 1921, “perfectly tit, nerves a bit
shaky at times, no stroke”: under obser¬
vation eight years and four months; no
retinitis present seven years and six months
after its first appearance

XLI I

E. g.

i April 13, 1909, retinitis in
| affected eye only

Thrombosis of central retinal vein : January
13, 1914, “quite lost her sight and been ill
many months, unable to leave the house
since last January ” ; retinitis present four
years and nine months before last report

XLIII

R. W.

155

| December 16, 1913, retinitis
affected eye only ; August
j 22, 1921, very little re¬
tinitis still present

: August 22, 1921, perfectly fit, no stroke,
j looks very well, blood-pressure 155 mm. ;

; retinitis known to have been present for
| seven years and nine months

XLIV

R. H.

66 j

245

March 23,1913, no retinitis ;

| February 2,1919, retinitis,
right eye

, February 2, 1921, no stroke at any time,
walks to hospital, blood-pressure 220 mm.:
under observation five years and ten
months ; retinitis seen on last visit only

XLV

G. H.

165

April 4, 1911, retinitis both
eyes

January 15, 1919, “general health very good,
never any stroke ” ; retinitis present seven
years and nine months before last seen

XLVI

J. B.

1 60

220

.June 12, 1913, retinitis in
affected eye only

Thrombosis of tributary of retinal vein;
nothing further known

XLVII
C. P.

222 ;

March 7, 1914, retinitis right
eye; March 24, 1916;

retinitis disappeared; Jan¬
uary 18, 1919, no retinitis

January 18, 1919, a year ago awoke suddenly
with a giddy feeling which has never gone
off, blood - pressure 210 mm.; retinitis
present four years and ten months before
last seen

Analysis of Cases in the foregoing Table.

Forty-seven cases in all. Thirty of these are known to have ended fatally,
and the cause of death is known in twenty-eight of them. Seventeen were
alive when the latest information with regard to them was obtained, and
of these there was satisfactory evidence that four had suffered from a gross
vascular cerebral lesion.

Prognosis as Regards Life. —The average duration of life after the discovery
of retinitis in the twenty-eight fatal cases was two years and eight months, and
fifteen of them (i.e., 53 per cent.) lived for more than two years. The average
duration of life of thirteen cases who were alive when the last information with
regard to them was obtained was five years and five months. If one takes the
forty-one cases, fatal and otherwise, in which the length of survival after the
discovery of the retinitis is known, it works out at three years and 6'6 months.

Cause of Death. —Of twenty-eight fatal cases where the cause of death is
known, fourteen, i.e., 50 per cent., are known to have died of a gross vascular
cerebral lesion. In three cases only is nephritis or uraemia given as the cause
of death. Of seventeen cases who were alive when the last information with
regard to them was obtained, four were known to have suffered from a
gross vascular cerebral lesion.

Retinitis. —Of forty-five cases the retinitis was unilateral in twenty-eight
(i.e., 60*7 per cent.). In Cases XII, XXVIII, XXX, XXXI, XXXV,

Sections of Medicine and Ophthalmology 15

XXXVIII, XLI, and XLVII, the retinitis disappeared whilst under
observation.

Urine .—In seventeen cases at least the urine was intermittently free of
albumin.

Mr. Percy Bardsley (Salisbury) :

I have long held the views of Dr. Batty Shaw on the toxaemic origin of
retinitis and sclerosis.

Mr. Foster Moore kindly sent me a copy of his paper to study in advance.
I agree with all that he has written in that paper, but, in the short time
allowed me this evening, I must bring forward a somewhat different view.

While admitting that the picture of arterio-sclerotic retinitis, which he
has so carefully and ably drawn, is correct in every detail, I think that picture
only applies to cases of great cbronicity. In other words, the retinitis depends
on the acuteness of the disease producing the sclerosis. If the toxin is of a
more drastic nature, or if exacerbation of the disease takes place, then the
picture produced is indistinguishable from so-called renal retinitis.

Now the classical changes in so-called renal retinitis are four: (l) The
retinal oedema, resulting in radiating lines or in a macular star; (2) the fatty
spots; (3) the haemorrhages ; (4) the high pressure signs in the vessels.

These four cardinal signs may all be present in three groups of cases
without albuminuria, viz.: (.4) In intracranial pressure; ( B ) in advanced
arterial sclerosis, perhaps I should say acute arterial sclerosis; (C) in many
toxaemias. For instance, I myself have seen: (a) Several cases of syphilitic
retinitis; ( b ) two cases of post-influenzal retinitis ; (c) one case of unknown,
but supposed cerebro-spinal origin ; ( d) also two monocular cases of pyorrhoeic
origin. In all these cases the four classical signs were present, and
without albuminuria; yet they were indistinguishable from renal retinitis.

Since, then, these retinal signs occur so frequently without albuminuria,
and since albuminuria can only be diagnosed by urinalysis, and not by the
ophthalmoscope, I ask: “ Is it not time that this misleading term 1 renal
retinitis ' should be abolished ? "

How, then, does the ophthalmoscope help us in these cases ? It informs us
that there is a toxaemia causing high blood-pressure and vascular inflamma¬
tion with its accompanying sequelae. The toxin may or may not at the same
time be causing albuminuria; this is shown by urinalysis. The ophthalmo¬
scope shows us also what is of the utmost importance, viz., whether this
inflammation is accompanied or unaccompanied by sclerotic changes in the
vessels walls.

This is of the utmost importance , for the prognosis of life or early death
largely depends upon it.

If the ophthalmoscope shows advanced sclerosis, together with gross retinitis
and albuminuria, then I believe the termination of life may be forecast in
months, or even in weeks. If, however, the retinitis shows only high blood-
pressure with little sclerosis, then the chance of recovery and fair length of
life is good; the poison may be evacuated, the blood-pressure reduced, and no
gros9 sclerotic changes left in the vessel walls. Of course, if the toxin is not
acute enough to produce a retinitis, or only a mild form of retinitis, the
prognosis is not so grave, even with advanced sclerosis. The sclerosis is the
index of the cbronicity of the poison, not of its acuteness. If you reject for
the army the man with the hypertrophied heart because he is less able to

16 Bardsley—Adams : Arteriosclerosis and Renal Disease

endure, you should also increase the premium of the life assurance policy
of the man with hypertrophied arteries. That man will not withstand the
toxin that produces retinitis as a man with normal arteries will.

Here I must challenge one statement made by Dr. Batty Shaw. He says :
“ Thickening of the middle coat produces the silver or copper-wire appearance
of the retinal arteries.” Now silver and copper-wire have very different
sheens, and the respective sheen of each bears a very different interpretation.
To-day I may see a patient whose arteries show neither. Next week, after a
severe influenza, I see that patient with broad copper-bright light streaks and
indented veins. The brachial blood-pressure reads 160 to 170. Have those
arteries become sclerosed in two or three days ? No ! In a few weeks they
may be back to normal.

Is it possible, then, to distinguish between the signs of simple high blood-
pressure and the signs of arterio-sclerotic changes ? I have stated in the past
that this is possible, and, after five years’ interval, I confidently reiterate
that statement.

I would also emphasize a point that I think is not clearly grasped, namely,
that one can detect sclerosis in the vessels when high blood-pressure is not
present, and can thus forewarn the physician and the patient. Of this the
following is rather a striking illustration :—

In 1911 a medical man sent his wife to me for refraction. Her age was 31. They
had one child, aged 11.

After careful observation I wrote him that in my opinion it would be unwise to risk
a further pregnancy, as her vessels showed considerable sclerosis. He was naturally
very upset, and he took her to a well known physician, who found her blood-pressure
a little under 130, and while he thought this perhaps a little high for her age, attached
no significance to it.

A little later the lady became pregnant. At seven months albuminuria and
eclampsia set in : the child was delivered, and died shortly after birth ; the wife
took more than a year to recover. She is still alive, and enjoying moderate health.

Mr. Philip Adams (Oxford).

With reference to the so-called “renal ” retinitis, this condition appears to
be rare in the district in which I work. I hardly ever see a case nowadays,
either at the Radcliffe Infirmary or the Eye Hospital, and yet I remember
seeing it fairly often some years back. Only last week I was asked to examine
the eyes of a man in the infirmary with chronic interstitial nephritis, but the
condition present was one of arterio-solerotic retinitis in one eye, thickened
arteries and a hemorrhage in the other. In contrast to this, towards the end
of the war I was asked to see a man with a wound in the hip-joint, who was
complaining of blurred vision; he had absolutely typical “ albuminuric ” or
“ renal ” retinitis, slight papilloedema, soft cotton-wool patches and hemor¬
rhages, with a stellate figure at each macula; but in spite of repeated
examination of his urine nothing abnormal was found, except a vary slight
trace of albumin on the first occasion. His wound was very septic and
draining badly, and he was extremely ill, but after amputation and free drainage
he quickly recovered his health and sight, and he is alive and well at the
present time. This case, shows, I think, that toxicmia can of itself cause
the condition known as “ renal ” retinitis, without involvement of the kidney.

With regard to Mr. Foster Moore’s propositions, I quite agree that there is

Sections of Medicine and Ophthalmology

a distinctive condition of the fundus oculi, which he has named arterio¬
sclerotic retinitis, but I am inclined to think that the explanation of the
condition given by Dr. Batty Shaw is likely to prove the correct one.

Again with regard to the length of time these patients live, my experience
is similar to that of Mr. Foster Moore. Some years ago 1 I collected 159 cases
of retinal vascular disease, exclusive of true “ renal ” retinitis, but including
arterio-sclerotic retinitis and other retinal lesions associated with arterio¬
sclerosis, and I found that the patients in many of these cases lived to
an advanced age provided their urine was free from albumin, whereas if
albumin was present, eight or nine years was the maximum and this was quite
the exception. Again, speaking generally, the older the patient at the time of
onset of the eye symptoms, the less serious was the prognosis.

The more I ponder over my cases of vascular disease of the retina in
arterio-sclerosis, the more convinced am I that one cannot make any prognosis
on the eye condition alone ; this must depend on the associated condition of
the heart and kidneys. What is wanted, it seems to me, is, a comparison
of the length of life between arterio-sclerotic patients who show no retinal
change and those that do, because not all cases of arterio-sclerosis show
distinguishing retinal changes, though the majority do so; and then one could
form some idea of the true significance of these changes. This research could
only be carried out conjointly by a physician and an ophthalmic surgeon
working together.

Dr. Arthur Ellis.

At the London Hospital, Dr. Marrack and I are attempting to determine
the relationship between disturbance of renal function and the occurrence of
retinitis. With this end in view we are making a careful study of renal
function in all patients in whom retinitis is determined. The tests of
renal function employed consist in observations as to the presence or absence
of albumin and casts, the determination of blood urea, the estimation of the
power of excretion of phenol-sulphone-phthalein, the urea concentration test
and observations on the occurrence or non-occurrence of fixation of the specific
gravity of the urine. Up to date, twenty cases have been examined and the
results obtained are shown in the following tables:—

Examination of these tables reveals two facts of major importance, first the
constancy of high blood-pressure in these patients and second the possibility
of separating them into two groups, one with gross disturbance of kidney
function, the other without evidence of such gross disturbance.

(1) High Blood-pressure. —With one exception all the patients with retinitis
examined showed high blood-pressure. In only three of the twenty was the
systolic pressure less than 200 : in one it was 180, in one 160, while in
one patient the relatively low pressure of 148 mm. of mercury was found.

(2) Differentiation of Cases according to Renal Function. —In Table I are
given those cases of retinitis in which gross disturbance of renal function was
determined. It will be seen that in all nine there was marked urea retention,
the figures for blood urea being in all these patients over 100 mg. per 100 c.c.
There was also gross disturbance of phenol-sulphone-phthalein(P.S.P.)excretion,
in six of the nine patients the excretion being either nil or only a trace. The
urea-concentration test also, in every case in which it was carried out showed
marked impairment of renal function, the ability to concentrate urea in the

1 S<*«» Brit. Journ. Ophth 1017, i. p. lf»l.

Ai j - M iV O 2

Table I.—Retinitis with Gross Disturbance of Renal Function.

Ellis: Arteriosclerosis and Renal Disease

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Sections of Medicine a?id Ophthalmology

urine being in the neighbourhood of or under a concentration of 1 per cent.,
instead of the normal of over 2 per cent. In six of the nine patients there was
fixation of the specific gravity of the urine. Four of these nine patients are
known to have died of uraemia, one is dead of broncho-pneumonia and two
others are dying of obvious renal inefficiency.

In Table II are given the findings in those cases of retinitis in which
evidence of gross disturbance of renal function was lacking. There are eleven
patients in this group. In only one was there any evidence of nitrogen
retention: this patient had on admission 80 mgm. and two months later
60 mgm. of urea per 100 c.c. of blood. It will be noticed that in this patient
the phenol-sulphone-phthalein figure was also the lowest for any patient in the
group and the urea concentration also below normal. The patient was suffering
from cardiac failure and it is probable that the poor figures for renal excretion
were in part dependent on the circulatory failure. In the other ten patients
the figure for blood urea was within normal limits. The phenol-sulphone-
phthalein excretion was less than the normal in more than half the cases
in the group, but with the exception of the patient showing urea retention it
did not approach the condition found in cases of advanced renal disease.

The results of the urea-concentration test in this group of patients was
particularly interesting. In only three was the figure below the normal
2 per cent. One of these three was the patient already mentioned with urea
retention and low phenol-sulphone-phthalein, the other two were both cases of
retinitis occurring in pregnancy—a retinitis recognized by the ophthalmologists
as different on account of its much more favourable prognosis. None of the
patients in this group showed fixation of the specific gravity of the urine.
Of this second group of patients three only are known to be dead, one of
cerebral haemorrhage and two of cardiac failure. It is to be noted that
two other patients in this group are hemiplegic.

We see then that patients with retinitis may be divided into two groups,
one showing gross impairment of renal function, the other not. In the former
death usually occurs relatively soon after the patient seeks admission to a
hospital, the common termination being uraemia. In the latter, life is more
prolonged but vascular accidents are frequent and are probably the common
eventual cause of death.

With what are we dealing in these two groups ? This opens up an
interesting question. Are they the same disease, one being an advanced stage
of the other, or are they two separate and distinct diseases ? Is one primarily
a renal disease with a secondary rise of blood-pressure, and the other primarily
a high-pressure disease with renal involvement merely as a secondary result?

If the renal cases do represent the end stage of a disease the earlier
manifestations of which are seen in the “ vascular ” group, then we should
expect the patients listed in Table I to be older and to have higher blood-
pressures than those in Table II. The reverse proves to be the case, the
average age in the “renal” group being thirteen years younger than in
the “vascular,” and the average blood-pressure in the “vascular” group
15 mm. higher than in the “ renal.” This is in keeping with experience and
m agreement with the generally accepted differentiation of two diseases,
,fl ) chronic nephritis with high blood-pressure, and ( b ) essential vascular hyper¬
tension with secondary renal damage. Is there a different ophthalmoscopic
picture in these two conditions ? Will these ophthalmoscopic appearances
coincide with Mr. Foster Moore’s renal retinitis on the one hand and arterio¬
sclerotic retinitis on the other ? These are questions whichre quire answering,
and to-day’s discussion should help to hasten their solution.

Ap-M »* 0 2 a

20 Hawthorne —Gaskell: Arteriosclerosis and Renal Disease

Dr. C. 0. Hawthorne.

5 C I propose to limit my remarks to the various descriptive or diagnostic terms
that have been proposed in the debate: these terms have been suggested as
appropriate when retinitis is associated with renal disease on the one hand, and,
on the other, when retinitis is free from that association but exists in the
presence of more or less conclusive evidence of arterial degeneration. In Dr.
Batty Shaw’s view the retinitis existing in these two sets of circumstances is
one and the same: it is due to a toxic condition of the blood, and is produced
by a direct action of the toxin on the retinal tissues. Hence Dr. Batty Shaw
wishes to call the condition toxic retinitis. On the other hand, Mr. Foster
Moore recognizes two forms of retinitis, though he admits he is not always able
to distinguish the one from the other. One form Mr. Foster Moore regards as
a result of advanced degenerative change in the retinal vessels, and he therefore
calls it arterio-sclerotic retinitis ; and the other he takes to be an expression of
renal disease, and hence he applies the term renal retinitis.

I challenge both sets of proposals, not on the ground that the underlying
propositions are not true, but on the ground that we do not know them to be
true. Hence it follows that terms implying their truth ought not be admitted
to a scientific vocabulary.

Each of these terms—toxic retinitis, renal retinitis, arterio-sclerotic retinitis
—involves an undemonstrated speculation or hypothesis, and this consideration
alone is sufficient to condemn such terms as bad and as inadmissible to a
scientific nomenclature ; for scientific terms, if pretending to be descriptive,
should be descriptive of facts and not of opinions about facts. Already in
medicine there are more than sufficient areas within which confusion is per¬
petuated and counsel darkened by words without knowledge ; and any extension
of this method should be resolutely resisted.

Dr. Batty Shaw knows nothing of his hypothetical toxin, except from what
he judges to be its effects; he cannot tell what the toxin is, nor w T here it
comes from, nor how it acts. It is one thing to teach or to argue in
favour of a certain theoretical explanation, and quite another thing to
impose this explanation as settled doctrine by incorporating it in a descriptive
title.

Similarly, Mr. Foster Moore’s terms are obviously speculative or hypo¬
thetical. In time they may turn out to be justified, but at present they are
far in advance of the facts. There is the more reason for circumspection here,
seeing that Mr. Foster Moore allows that the two pictures he draws are not in
all cases confidently distinguishable the one from the other.

In a word, it may be urged that into clinical names and phrases we ought
not to introduce terms implying a confident knowledge of causation, when, as a
matter of fact, such knowledge is not in our possession.

Dr. J. F. Gaskell (Cambridge).

I will endeavour to give my views as shortly as possible on those forms of
disease which bear upon the present discussion.

The point in this discussion I want to emphasize above all others is that
two conditions of entirely different pathology are concerned: one being
primarily a disease of the kidneys, the other of the vascular system as a whole.
It is inevitable, owing to the close interdependence of these two systems,
that lasting disease of one should affect the other, so that a composite
picture is ultimately formed in which both systems are affected.

Sections of Medicine and Ophthalmology

Dealing first with the condition which is primarily renal, I hold that the
initial occurrence is an acute inflammation of the whole organ, in which every
structure of which it is built up is involved—glomeruli, tubules, their sup¬
porting or interstitial tissues, and very probably the intrinsic blood-vessels of
the organ also.

There are various stages of this diffuse nephritis with which are usually
associated those forms of retinitis called albuminuric, or better, renal
retinitis.

The great damage which the kidney thus undergoes calls for an increased
efficiency in the circulatory system in order that the excretory function should
be adequately carried on, and cardiac hypertrophy and increased blood-pressure
result. The essential pathology is still however renal, and the one danger to
be apprehended in the later stage, where such an hypertrophy has been suc¬
cessfully brought about, is renal failure in the form of uraemia.

The second condition is a cardio-vascular one in which three factors invariably
take part—a raised blood-pressure, cardiac hypertrophy and disease of the small
arterioles of certain organs of the body. Organs which are always affected are
the brain and the kidney, around which the discussion turns to-night. It is to
this class that I consider Mr. Foster Moore’s series of cases belongs, and I am
fully in agreement with him that they should be separated from any connexion
with renal conditions. Another point that I want particularly to emphasize is
that in the purest examples of this condition the vascular changes, which
are degenerative in nature, are entirely confined to the small peripheral
arterioles. The largest arteries are wholly free from any such change; on the
contrary they frequently manifest a true muscular hypertrophy enabling them
to cope with the increased pressure of the blood-stream.

In these cases the cause of death is almost always to be traced to the
changes which occur in the brain, cerebral haemorrhage being by far the
commonest occurrence. There is, however, another group of events depending
upon relative failure in the cerebral circulation, which also leads to death.
The disease of the cerebral arterioles, especially in the medulla, becomes so
great that a local cerebral anaemia is brought about if the high level of the blood-
pressure is not maintained. Death often follows without gross cerebral lesion,
but with signs of respiratory failure, such as Cheyne-Stokes breathing, &c . This
condition must not be confused with uraemia.

With regard to the cause of this condition and the sequence of the three
chief events, it is very difficult to form an opinion as to whether the arterio¬
sclerotic changes of the arterioles are secondary to the high blood-pressure,
or whether the high blood-pressure is a response to obstruction to the peri¬
pheral circulation through essential organs. I do not myself consider that the
invoking of a “ toxaemia ” without any evidence of its nature adds to the clear¬
ness of any view of the pathology of this condition. I am, however, in hearty
agreement with the opener of the discussion that the changes are due to some
cause which acts upon the circulation as a whole, and that the sooner terms
such as chronic interstitial nephritis, which imply that the kidney is the primary
cause, are given up, th6 better. The term I incline to adopt for the condition
is one which we owe to Sir Clifford Allbutt, namely, “ hyperpiesis,” which both
draws attention to the circulatory system as the primary system involved,
and emphasizes one, and perhaps the primary, of the factors which constitute
the pathological entity.

(The Discussion was adjourned till December 8, 1922.)

Sections of flDebfcfne anb ©pbtbalmologp.

JOINT MEETING.

Chairman—Mr. A. L. Whitehead, President of the Section of

Ophthalmology.

ADJOURNED DISCUSSION ON “ THE SIGNIFICANCE
OF VASCULAR AND OTHER CHANGES IN THE
RETINA IN ARTERIO-SCLEROSIS AND RENAL
DISEASE.”

Mr. Ernest Clarke.

I think we shall find that when their statements have been thoroughly con¬
firmed the excellent papers of Dr. Batty Shaw and Mr. Foster Moore will be
really “ epoch-making.” What many of us have been long suspecting has at
length materialized. Those who can go back as many years as I can will
remember that we were taught (and believed all this time until recently) that
high blood-pressure was the cause , or one of the causes, of so-called “ hemor¬
rhagic retinitis ” in the majority of cases. We sent our patients to a physician
for him to lower the blood-pressure, and fortunately for the patient, even
bleeding did not do this. Now we are beginning to see that high blood-
pressure is not the cause, but one of the symptoms (we may even believe that
it is a protective measure ), and we must go further back for the cause which
in most cases is some form of toxaemia. This being so, is not the term
“haemorrhagic retinitis” (which most of us disliked because of its unscientific
style) probably the best term we can use at present as indicating the trouble
and not binding us to any theory (and thus it would, I suppose, meet with the
approval of Dr. Hawthorne).

Mr. Foster Moore, under “Proposition 2,” makes this remark :—

“ If, as I believe, the presence of exudates in the retina implies a stage of arterio¬
sclerosis in advance of a case in which vascular disease alone is evident, and if, as I
am sure is the case, the disease of the retinal vessels increases pari passu with the
general arterial disease, then a comparison of two groups of patients—in one of which
vascular disease alone is present, and in the other of which exudates are present in
addition to the vascular disease—should provide evidence that the latter group is com¬
posed of patients suffering from a further advanced stage of the disease.”

This of course tallies with the statement made by Dr. Batty Shaw, who
suggested that the different stages of disease are due to the amount of poison,
and the time during which it is acting.

With reference to the so-called “exudates,” why should they be present in
one eye and not in the other? Is it due to the same cause which we think

[December 8 , 1922 .

Sections of Medicine and Ophthalmology

operates in unilateral haemorrhage, namely, that the tension of the affected
eye is lower than that of the other? It would be a useful investigation if, in
the future when we find haemorrhages or exudates, or both, in one eye only,
we were to take the tension of both eyes with a tonometer.

We ophthalmic surgeons are quite familiar with retinal haemorrhages
occurring when the tension of the eye is lowered; it is an unfortunate accident
which may occur in doing an iridectomy for glaucoma, or extracting a
cataract, but we have always assumed in these cases that the vessels were
diseased.

Dr. Batty Shaw has very rightly hinted that the thickening of the middle
coat and of the intima strengthens the vessels, and we have sufficient evidence
to show that this thickening or sclerosis is inflammatory in origin and is only
followed by degenerative changes if the blood supply is deficient. Both the
openers of this discussion have suggested that the haemorrhages do not come
from ruptured vessels. Dr. Batty Shaw suggests that a haemorrhage may be of
the nature of a leakage from the capillaries ; this would seem to be confirmed
certainly in those cases in which small haemorrhages are unaccompanied by any
retinitis, and which disappear without leaving any trace, and appear to be un¬
associated with any constitutional disease. Such cases, I take it, constitute
an example of the first stage which, if allowed to continue, may develop into
so-called “ arterio-sclerotic retinitis,” which itself, if allowed to continue, or if
the toxins are increasing, may lead to renal disease, and so eventually to the
final stage of “ renal retinitis.”

Dr. W. N. Goldschmidt.

The success of any attempt to divide up cases of retinitis into those
due to renal “mischief” and those due to other disorders depends partly on
the decision as to what symptoms and signs, apart from retinitis, justify the
labelling of a case as “renal.” The following record illustrates the difficulty
of this problem.

It is of interest from the point of view of the relationship between the
symptoms and signs of “ parenchymatous nephritis ” and the condition
actually found in the kidneys, both during the disease and at the post-mortem
examination. The effect of decapsulation and other remedies is also discussed.

On January 28, 1922, a man aged 42 was admitted to hospital complaining of
swelling of his legs for seven weeks and of his ” stomach ” and back for six weeks.
Additional symptoms were very troublesome, viz., flatulence, shortness of breath on
exertion and occasional headaches. The only serious illness from which he had suffered
was a febrile attack C‘ influenza ”) in Egypt in 1918. There was no venereal history.

Condition on examination : There were great pallor and marked (edema of legs,
abdomen and back, and also ascites. The eardio-vascular system showed no abnor¬
malities, though the heart sounds were very faintly heard. The systolic blood-pressure
was 132 nun. In the respiratory system there was evidence of some pleural effusion at
l>oth bases, especially the right. The tongue was furred, the tonsils rather injected and
the gums showed pyorrhoea. The abdomen was distended, not only by fluid but by
meteorism as well, especially in its upper part. He complained of a dull pain all over
his abdomen and great flatulence after meals. Urine: About 200 c.c. were passed in
twenty-four hours, specific gravity 1030, brown in colour, acid, and containing about
2 per cent, of albumin : microscopic examination showed red blood cells and numerous
granular, hyaline and epithelial casts: the urea-concentration by Mac Lean’s test was
nearly normal, averaging 1*7 per cent. The blood-urea was within normal limits
<33 mg. per 100 c.c.). The Wassermann reaction was negative. The fundi, examined
ten days after admission, were normal.

*21 Goldschmidt: Arteriosclerosis and Renal Disease

Treatment at first consisted of rest in bed, salt-free diet and a diuretic mixture
containing potass, acetat., tr. scillae, sp. aether, nit. and succ. scoparii. In four days
the quantity of urine passed in twenty-four hours rose to 660 c,c. On the sixth day
hot-air baths once daily were used, but no satisfactory perspiration was produced. The
bowels were also very obstinate, and large doses of jalap, given with hot water, were
required to achieve any result. On the tenth day, urea (1 dr.) was given four times
a day for a few days, without any effect on diuresis, and then diuretin (20 gr. t.d.s.), but
with no result: the urine continued to average about 500 c.c. daily. He was drinking
fairly freely, but little fluid was excreted, either by the skin or by the bowels. The
flatulence was very troublesome, and had to be relieved by hot applications and
carminatives.

Since no progress was being made by the aid of medicinal and dietetic measures,
and since the history was comparatively short, it was decided that the effect should be
tried of decapsulating a kidney. Accordingly three weeks after admission his right
kidney was dealt with in this way by Mr. Gwynne Williams. One kidney only (the
right) was operated upon to begin with, in order to watch the result. The kidney
was found to be of normal size and colour: a slit was made in the capsule (which was
not tense) and a small piece of kidney substance was removed for examination: the
capsule was then separated from the kidney all round. The peritoneal cavity was
opened and 2 to 3 pints of ascitic fluid allowed to escape : this was milky and opalescent
from the presence of lecithin-globulin (Dr. Mackenzie Wallis). The intestines were pale
but there was no visible peritonitis.

Four days later the urine had risen to 900 c.c., and the oedema was rather less:
ten days after the operation it rose suddenly to 1,200 c.c. (albumin, 0*36 per cent.), but
within four days it dropped as quickly to 600 c.c. Urea was now again tried and
pushed in doses of 15 grm. t.d.s. except when the patient was sick; the urine now
increased within eighteen days to 1,600 c.c. in twenty-four hours and then averaged
1,200 c.c. for about twelve days. The general condition of the patient was, however,
but little altered and the oedema not materially diminished. The abdomen and scrotum
were again tense.

With the idea that the increased urinary output might have been due partly to the
operation, it was decided to decapsulate the left kidney. Accordingly, on April 5, 1922,
seven weeks after the first operation, a second operation was performed by Mr. Gwynne
Williams. The kidney and its capsule were normal in appearance and size : the capsule,
which w'as not tense, was slit and retracted: the peritoneal cavity was opened and
several pints of milky fluid like that at the first operation were removed. The intestines
were pale but otherwise normal. For the next two days the quantity of urine dropped
to 700 c.c., albumin still being present. On the third day the urine rose again to
1,350 c.c., but after that it steadily decreased in amount and the oedema reaccumulated.
Three weeks after the operation an attempt was made to reduce the oedema by giving
him less to drink (only about H pints daily), salt-free diet, purgatives and theocin sod.
acet. 4 gr., tr. digitalis 7i minims, and sod. sulph. 15 gr. t.d.s.: the increasing oliguria
could not be stayed.

On April 27 the blood-urea had risen to 48 mg. in 100 c.c. The abdomen was now
very distended again and vomiting started. On May 9 everything else having failed to
relieve the oedema it was considered justifiable to insert Southey’s tubes into his feet,
which was done with scrupulous aseptic precautions. A very large quantity of fluid
was drained off (4 pints on the first day). The abdominal distension, which was partly
gaseous, was not relieved. The chlorides in the urine were distinctly diminished.

After a few days the feet became red and painfnl : the temperature dropped to
9 if F.; the blood-pressure, which had been 132 mm. Hg on admission, soon dropping
to 120 mm. where it remained, now fell to 90 mm., and he became drowsy and
sometimes semi-conmtose. On May 30 his blood-urea had risen to 63 mg. in 100 c.c.
The albumin in his urine on June 1 was 0*5 per cent., on June 2, 1*25 per cent., and on
June 3, 2*5 per cent. He was now somnolent, often sick, and there was evidence
of cellulitis in the legs. He died on June 5.

Sections of Medicine and Ophthalmology

Alt topSXJ.

Externally a few petechiee were seen on the arms. Incisions into the dorsa of the
feet showed the cellular tissues to be distended with pus. . Heart was small, only 5£ oz.
in weight, and atrophic. The heart muscle was dark brown. A few patches of
atheroma were seen in the aorta and coronary arteries. Lungs, &c.: Each pleural sac
contained about 6 oz. of clear fluid: scattered fibrous adhesions on both sides. The
lungs were congested and oedematous. Peritoneal cavity contained a large quantity
of turbid ascitic fluid; considerable flakes of fibrinous exudate on the peritoneal
surface. Intestines : Sigmoid colon contracted, apparently by thickening of bowel walls ;
mucous membrane showed slaty-grey patches, and was oedematous and congested ; no
ulceration or evident scarring; the affected area was sharply marked off from the
contiguous normal gut.

Kidneys : The left kidney, normal in size, was removed and injected with pre¬
servative fluid soon after death. The right kidney, of normal size and weighing 5 oz.,
was not injected with preservative fluid ; the surface was smooth and rather pale ; the
cortex and medulla were normal, and so were the vessels.

Microscopic Sections of the Kidneys. —(Described by Mr. T. W. P. Lawrence.)

“ (1) Section of right kidney, piece being removed at the first decapsulation
operation : (a) There is localized cloudy swelling and necrosis of the tubules, probably
of an acute nature ; adjacent areas are quite normal. (6) There are some slight
chronic changes shown by thickening of the capsules, (c) There is proliferation of
the epithelium of the glomerular tufts, (rf) There is slight increase of the interstitial
tissue between the tubules in places, (e) There are small localized effusions of red
corpuscles.

(2) Section of right kidney, piece being removed at the post-mortem examination,
the organ not having been injected with preservative fluid: {a) All acute changes
above described are absent. (b) Chronic changes are shown by thickening of the
capsule, only slight, as above, (c) The numbers of nuclei in the glomerular tufts are
fairly normal. The corpuscles are not so large as in the above section, (d) Slight
interstitial changes between the tubules, as in the above section. (e) No effusion
of red corpuscles. (There is considerable autolytic change in the tubular
epithelium.)

(H) Section of left kidney, piece being removed at the post-mortem examination,
the organ having been injected with preservative fluid very soon after death: The
microscopic details of this kidney were identical with those met with in the right
kidney (see (2) above), no acute cloudy swelling or necrosis being visible in the tubular
epithelium. The autolytic changes were minimal.

Summary. —The sections of the piece of kidney removed during life showed slight
but definite changes, such as could be produced by some toxic agent arriving by the
blood-stream. The sections of the pieces removed after death only showed the
flight chronic changes met with in the sections of the piece removed during life,
and were very little different in appearance from those of a normal kidney.”

Comment on the Case.

This man died from an illness, the symptoms of which were typically those
which have been attributed to “ chronic parenchymatous nephritis but his
kidneys were found at the post-mortem examination both to be normal macro-
seopically and practically normal microscopically. His actual death was
perhaps due to or hastened by the infection which followed insertion of
Southey’s tubes, but he was steadily progressing to the inevitable end before
the use of these was reluctantly resorted to. The section from the piece of
right kidney taken during life at the first decapsulation operation showed some
parenchymatous changes of an apparently acute nature. As the right kidney
showed none of these appearances at the post-mortem examination, decap-

26 Goldschmidt—Davies: Arteriosclerosis and Renal Disease

sulafcion may have restored the kidney, but did not improve the pre-renal
toxaBmia.

I am forced to the conclusion (unless in such cases one thrusts aside as
valueless all microscopical evidence of the presence or absence of disease)
that this long, insidious and fatal illness was not accounted for primarily by
the state of his kidneys. The heart was very small and in a condition of
brown atrophy ; this organ, therefore, though the condition of brown atrophy
is always looked upon as a secondary phenomenon and not a primary morbus
cordis sui generis , actually showed considerably more evidence of disease than
the kidneys. Even supposing the kidneys had shown parenchymatous changes
at the post-mortem examination, there would be no more reason for considering
the kidney degeneration primary than that of the heart. Incidentally, it must
be remembered that there were no signs of renal inefficiency during the earlier
and greater part of his illness, except oliguria (which occurs in heart disease),
albuminuria (which occurs in 6 per cent, of healthy adults), and diminished
excretion of chlorides (which occurs also in fevers, especially pneumonia, and is
not incontestably the result of damaged kidneys). Furthermore, the oedema is
not easy to explain as due entirely to the retention of chlorides, since oedema is
not a feature of pneumonia, and does not even occur in obstructive suppression
of urine or after removal of the only kidney. It is of great importance to note
that, although towards the end of- his illness the kidneys were only slightly
damaged or possibly not at all, the blood-urea rose, so that an abnormally large
amount of urea may be present in the blood with but slight or no changes in
the kidneys.

It would, therefore, seem as if this man’s illness were due to some pre-
renal poison which caused exudation into the tissues, and incidentally damaged
some of the tubules of the right kidney, but these latter had recovered by the
time the man died.

I wish to thank Dr. Batty Shaw and Mr. Gwynne Williams for kindly
allowing me to make use of their case reports, and Mr. Lawrence for his
description of the microscopical sections.

Mr. D. Leighton Davies (Cardiff).

I suppose the majority of ophthalmic surgeons will agree that there is a
distinct clinical difference between a haemorrhagic retinitis due to, or associated
with, marked arterio-sclerosis on the one hand, and a retinitis due to or
associated with albuminuria on the other. On the one hand we see a fundus
in which the disc has a deep brick-red colour, with round, irregular or flame¬
shaped haemorrhages scattered about the retina, but mostly somewhere in the
neighbourhood of the blood-vessels ; (it may be also that near these same
vessels a few small white spots can be seen) ; arteries glistening and rather
tortuous, and perhaps uneven in calibre, whilst the veins are full. Such is the
clinical picture of a retinitis associated with arterio-sclerosis.

On the other hand we have a fundus, of which the disc is perhaps of a pink
colour and the edges tend to be a little feathery ; a few haemorrhages may be
scattered about, but the striking feature consists in the patches of white
exudate large or small, irregular in shape and distribution, or arranged
symmetrically about the macula : such is the picture of an albuminuric reti¬
nitis, so-called. But not infrequently we meet with cases which are not only
difficult to place, but which, while resembling one or another of these two
clinical types, are the result of some totally different cause.

Again, these two clinical groups are quite distinct in the significance which

Sections of Medicine and Ophthalmology

they bear with respect to the prognosis of life. In the case of the arterio¬
sclerotic type we know quite well that the expectation of life is much greater
than in the albuminuric type.

In face of all these considerations I really cannot see that the views
enunciated by Dr. Batty Shaw are in any way helpful in the differentiation or
prognosis of arterio-sclerotic and renal retinitis. In effect he says that arterio¬
sclerotic and renal retinitis cannot be differentiated. Let us assume for a
moment that the arterio-sclerosis and the nephritis are but different aspects or
results of some hypothetical toxaemia, as indeed they may be. In one person
this toxaemia produces an arterio-sclerosis, in another a nephritis. Or again, it
may be assumed that one form of toxaemia is responsible for the arterio-sclerosis
and another toxin lies at the root of the nephritis. But whatever may he the
originating cause, they have at any rate produced two entirely different clinical
varieties (I use the word clinical advisedly, as opposed to pathological),
each of which has its own prognostic significance. And this, again, is in con¬
sonance with what we know of other forms of toxaemia, such, for instance, as
infections produced by the pneumococcus. At one time it may produce a
pneumonia, at another time a meningitis or, again, a synovitis. So that
although we have a common origin, yet we have widely differing clinical
pictures, each having different prognostic significance.

I will now refer to one aspect of arterio-sclerotic retinitis which has
already been touched upon, the relationship between sclerosis of the retinal
vessels and the condition of the vessels supplying the brain. A few years ago
1 read somewhere that the cerebral vessels may be distinctly atheromatous
without degeneration showing itself in the retinal vessels. This led me to
make a systematic examination of a number of cases of hemiplegia due to
cerebral arterial disease, with a view to confirming or disproving this state¬
ment. This investigation was, unfortunately, interrupted by the war, and I
have not had the opportunity of taking it up again. Of fifteen genuine cases
of apoplexy which I examined, nine cases showed marked arterio-sclerosis, the
most marked being in a female aged 41, who had a systolic blood-pressure of
230 mm. Hg and a trace of albumin in a urine of low specific gravity, together
with haemorrhagic retinitis. In four cases the signs of retinal arterio-sclerosis
were slight, whilst in two cases the arteries appeared to be perfectly normal.
One of these cases was that of a woman aged 45 who had been hemiplegic for
three years, in whom the blood-pressure was only 160 mm. Hg (D. 120). The
other case was that of an old man aged 71 who had had a stroke one year pre¬
viously, and whose blood-pressure was only 160 mm. Hg (D. 110). But what
is more germane to this discussion was the fact that out of these fifteen cases
only one jmtient showed hcemorrhagic retinitis, the case already alluded to.
Of course one lias seen many cases of haemorrhagic retinitis which have been
followed by stroke at varying periods. I have not been able to gather all my
cases together, for these fifteen cases represent only workhouse patients and
inmates. It would, however, be interesting to know r what is the frequency with
which hemorrhagic retinitis can be found in cases of cerebral apoplexy, and
their relationship to the blood-pressure.

Mr. M. S. Mayou

exhibited a series of pathological slides showing the various changes in the
retinal vessels together with the different forms of exudation into the various
parts of the retina. Pie raised only one point in the discussion—that of

28 Mayou—Newton Pitt: Arteriosclerosis and Renal Disease

nomenclature. It was proposed to manufacture a new term : arterio-sclerotic
retinitis. Pathologically, it was not a retinitis, but a degeneration, and if a
new term was introduced, care should be taken that it was a correct one,
e.g., vascular sclerotic degeneration of the retina.

Dr. G. Newton Pitt (President of the Section of

Medicine)

said it was very essential in the discussion of this question to draw attention
to what had been pointed out years ago; that the vascular changes which took
place in the aorta, in the small vessels, and in the arterioles were quite
independent, each of the others. Though one set of vessels might be diseased
it did not necessarily follow that all vessels were affected. There was a
tendency to assume that, in cerebral haemorrhage, for example, there was an
association with arterio-sclerosis. But when examining cases post mortem,
one found that there were a large number of cases of cerebral haemorrhage in
which the arteries, including the middle cerebral, did not show extensive
disease. It was true that where there was extensive disease of arterioles there
was more likely to be disease in the middle-sized arteries as well than if the
arterioles were healthy; but the diseases of the two were distinct, and the
presence of one did not justify a presupposition of the existence of the other.
That was a very important consideration, because the same applied in regard
to the kidney changes in cases of cerebral haemorrhage. The number of cases
of cerebral haemorrhage which had also marked interstitial nephritis was
very moderate, or comparatively so, though statistics varied as to the exact
proportion, continental figures being lower than our own. What he wdshed
particularly to insist upon was, that arterio-sclerosis must not be definitely
correlated with cerebral haemorrhage : though they might co-exist in the same
patient, they should be regarded as separate entities.

The same applied to the retina ; its vessels corresponded closely in size to
those from which cerebral haemorrhage occurred and were the only ones open
to inspection which gave an indication of the condition of the walls of the
arterioles in the brain. The figures Dr. Ellis gave at the first meeting on this
subject showed that, taking the early cases of retinitis in which there was no
evidence of inefficient kidney function and no excess of blood urea and in
which the kidney functions were fairly good, the majority of the patients died
of cerebral haemorrhage. The cases having excessive blood urea and evidence
of very inefficient kidneys were more likely to die of uraemia. What was
required to be known was, the relation between cases in which there was
death from cerebral haemorrhage and those in which death occurred with
retinal changes. At present, very few figures on the subject were available, as
in the wards the retinae were not systematically examined.

Whilst there were cases in which one felt that the retinal change indicated
renal change, there surely must be many cases in which, to a physician, it
was doubtful whether one was to look upon the change as vascular, or as
renal. W 7 hat was the experience of ophthalmologists on this point? Did
they claim that the two were quite distinct? There were some cases which
were definite, but there were a large number of cases with retinitis in which
one would not like to say what was the state of the blood urea or the condition
of the kidney, without making further examination.

The occurrence of cerebral softening and cerebral haemorrhage in these
retinal cases raised this question : Were the lesions due to rupture of a minute

Sections of Medicine and Ophthalmology

vessel, or to a thrombosis ? When a vessel was thrombosed there was an
infarct, and in many of the cases in which a small vessel was blocked there
were present the conditions for a small extravasation of blood just as much
as if the vessel had actually ruptured. When a small retinal haemorrhage
occurred, he was therefore not at all sure that this indicated the rupture of a
vessel. In many cases such haemorrhages were more indicative of thrombosis.

There was no doubt that the prognosis of the conditions was distinct.
Where there were retinal changes with distinct evidence of kidney inefficiency,
the prognosis was infinitely morq grave than when retinal haemorrhages
occurred and the kidneys were efficient. Personally, he would be much
more inclined to base his prognosis on the condition of the blood urea and
the kidney efficiency than simply on the appearances in the retina.

A very small proportion of cases with fatal uraemia due to interstitial
nephritis showed retinal changes, and in the most extreme forms of the lesion
often no retinitis developed. What was the additional factor which determined
that in a small proportion there should be retinal changes, and in the majority
not ? There were not sufficient data available for forming a definite conclusion
as to this; but merely to assume that there was a toxic condition which had
produced fatal nephritis did not sufficiently explain the fact that only in a small
proportion of the cases would there be this retinal change.

With regard to the blood-pressure: he did not think it followed that if
theie were arterio-sclerotic changes in the middle-sized arteries, the pressure
in the capillaries and the arterioles was necessarily raised. In many of the
cases having arterio-sclerotic vessels it was a question whether the tissues
were not suffering from too low rather than from too high a pressure.
And there was much evidence favouring the view that these conditions were
due to defective nutrition, and that it was a cutting off the blood supply
which caused exudations, as well as small haemorrhages.

Dr. A. Feiling

said the remarks he would make were based essentially on the study of thirty
cases in the last eighteen months, and they had been observed from the point
of view of the physician, not from that of minute changes in the fundus oculi.
All those thirty cases were referred to him by his ophthalmic colleagues, and
all sought advice in the first instance because of failure of vision, not for
symptoms referred to any other system of the body. For this discussion, he
tried to divide the cases into those which he would call arterio-sclerotic, and
those he would designate renal. In the majority he found it fairly easy, on
clinical grounds, to do so. The clinical symptoms he took for differentiation
were: (l) A history of any definite attack of acute nephritis ; (2) the persistent
presence of large amounts of protein in the urine; (3) the presence of well-
marked oedema. Cases presenting all those characteristics he classified pro¬
visionally as renal. And when the cases were followed into detail, they all
corresponded to the renal group, to which Mr. Foster Moore drew attention.

Of the thirty cases, he classified only five as renal—three males, two
females. The average age was 43*8 years, and all had well-marked bilateral
retinitis. One had had nephritis during the war, i.e., in 1918, and was for nine
months in hospital before he was considered well enough to be discharged.
The second patient said he was in a London hospital under Dr. Pavy twenty
years ago for acute nephritis. In the other three he was unable to get a definite
history' of acute renal disease, yet he did not think anyone would hesitate to
class them as renal. Of the renal cases, the average systolic blood-pressure
was 235 mm., and the diastolic pressure 135.

30 Feiling—Fisher: Arteriosclerosis and Renal Disease

In the group he called arterio-sclerotic, there were several points of differ¬
ence which were of great interest. Their average age was 63'3 years, which
was in contrast with 43 8 years in the renal group, and fifteen of the twenty-
five were females. Of the twenty-five, 60 per cent, had the retinitis unilaterally.
The average systolic pressure was 214, the diastolic 118. In both groups there
was high arterial blood-pressure, well-marked thickening of the accessible
arteries, and, generally, some hypertrophy of the heart which was evident upon
examination by ordinary clinical methods.

After discussing various hypotheses, illustrated from his own experience,
Dr. Feiling concluded that there should be hesitation about adopting any new
nomenclature in these conditions ; the toxic idea was only at present based on
theory, and to adopt the suggested new nomenclature implied the risk of
shutting one’s eyes to other causes, such as the mechanical one.

Mr. J. Herbert Fisher.

Referring to Dr. Batty Shaw’s opening address, I was particularly interested
in his advocacy of the substitution of such terms as “ minimal and maximal
toxic retinitis ” for arterio-sclerotic and renal retinitis. In 1915 I read a paper
before the Section of Ophthalmology on the retinitis of pregnancy, in which I
advocated the use of the term “ toxaemic retinitis of pregnancy ” l instead of
albuminuric retinitis of pregnancy. After all, we are in the midst of a dis¬
cussion, and some nomenclature has to be adopted unless our efforts are to
come to an abrupt conclusion. The obstetrician has advanced reasons for
believing that the pathological vomiting of pregnancy, eclampsia, acute yellow
atrophy of liver and the necrotic changes of the kidney cortex that accompany
the albuminuria of pregnancy are due to a toxin, and has suggested that the
toxin may be produced by perverted katabolic processes in the syncytium cells
shed from the chorionic villi at the placental site into the maternal circulation.
In all the various organs liable to attack, the stress of the lesions is upon the
blood-vessels, and hemorrhages in consequence are a conspicuous feature ;
and it seems at least reasonable to infer that the fulminating lesions in the
retina in these cases accompanied by exudates, haemorrhages and oedema, are
due to the same cause, and that in considering this variety of retinitis at any
rate we are getting pretty close on the scent of the nature and source of the
toxaemia.

At the other end of the scale it seems legitimate to take a glance at a variety
of retinitis in which the natural changes of advancing years produce such
alterations in the coats of the blood-vessels of the retina that exudates in the
retina, based on haemorrhage, result; I refer to retinitis circinata—a disease
of the later years of life—so chronic in character that its explanation on the

basis of the altered condition of the arterial tunics seems to fulfil every require¬
ment without invoking any conception of an absorption toxaemia. Nearly

twenty years ago I brought before the Ophthalmological Society 2 a boy, 13

years of age, who after acute rheumatism eight years earlier had developed
cardiac disease, and showed multiple aneurysmal dilatations on some of his
retinal arteries, clearly indicating very advanced changes in the arterial walls;
in his retina he presented an appearance of glistening exudate entirely com¬
parable to the senile cases of retinitis circinata. More recently, at a combined

1 Proceedings, 1915, viii (St*ct. Ophtli.), pp. 127-1JS.

- Trans. Ophth. Soc, Loud ., 1903, xxiii, p. 73.

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discussion on “Diabetic Retinitis,” a striking fact was confirmed, viz.: that
diabetic retinitis was rarely manifested in the most serious and fatal cases of
diabetes which attacked patients in the first half of life, while it was frequent
in the less serious cases of glycosuria occurring in the later half of life. It
would appear that the toxaemia was most intense in the cases in which retinitis
failed to manifest itself, and it was generally agreed that the milder toxaemia
of the other group was capable of producing the retinal changes by reason of
the sclerotic changes in the blood-vessel coats which had resulted from advan¬
cing years.

Most of the speakers in the present discussion have agreed that there is an
arterio-sclerotic retinitis, as well as the more familiar retinitis, which, for the
moment at any rate, we must still designate as an albuminuric or a renal
retinitis, and for the most part they are agreed that it is not in many instances
possible to distinguish absolutely, from the ophthalmoscopic appearances, be¬
tween the one and the other. Dr. Batty Shaw inclines to the view that
whether albuminuria be present or absent the cause is a toxaemia. It has been
shown that in one group of cases in which the kidney functions well the pro¬
gnosis for life is by no means so dismal as in the other. As an alternative to
Dr. Batty Shaw’s view, it has been suggested in the course of the discussion
that in the unfavourable cases interstitial fibrosis of the kidney initiated by some
acute nephritis is the primary disorder, and that the cardiac hypertrophy, with
the resulting arterial thickenings, is a compensatory phenomenon, and assists
the impaired renal tissue to function, though still indifferently; while in the
cases which are arterio-sclerotic and attributable to some form of as yet
unrecognized toxaemia, the cardiac hypertrophy must necessarily follow to
drive the blood-stream against the increased resistance, but, that with this
assistance, a reasonably sound kidney still functions well and serves an admir¬
able purpose by eliminating the toxins from the blood. Dr. Batty Shaw
appears to incline to the view that the toxin is likely to be the same but of
different intensity in the two varieties of disorder, both of which are capable
of producing retinal changes, and these changes to a large extent indistinguish¬
able. Such a view seems to derive some support from the fact that though life
may be much more prolonged in the cases in which there is no albuminuria,
yet the causes of death, when it comes, are at any rate in many instances
identical with those w T hich produce death in a comparatively few months after
retinitis develops in the presence of kidney insufficiency. If we accept the
toxic explanation of both varieties, it appears reasonable to expect that in the
arterio-sclerotic cases with efficient kidneys, the toxin should be found
abundantly in the urine, but in low concentration in the blood ; while in the
albuminuric cases, where elimination of the toxin by the kidney is impeded,
the toxin should be found in concentration in the blood, but sparsely in the
urine. Might it be that comparative records of analysis of blood and urine in
the two classes of cases by chemical pathologists will put us on the track of
a toxin which at present is hypothetical ?

It appears, therefore, to me that in the retinitis of pregnancy we have a
manifestation which is typically toxaemic in origin ; that retinitis circinata
affords an example of a retinitis with haemorrhages dependent on sclerosis of
retinal vessels ; that in diabetic retinitis we see the effects on the retina of
specific chemical toxins capable of operating only in the presence of those
changes in the w T alls of the blood-vessels which are common to all mankind as
age increases. That in arterio-sclerotic retinitis and in so-called renal retinitis
we have yet to discover a toxin, which quite probably may be common to both,.

32 Harford: Arteriosclerosis and Renal Disease

and which is in greater intensity in the blood and body tissues and likely
therefore to prove destructive to life at an early date only if the kidney is
impaired in its function as an organ of elimination.

Dr. C. F. Harford.

It seems to be clear from the introductory paper of Dr. Batty Shaw and
from subsequent speakers that there is no such close relation between changes
in the retina and disease in the kidneys as common tradition has sketched
for us. This being so, it is our plain duty to review this subject from every
point of view and in the meantime we should refrain from giving the grave
prognosis which has previously been suggested, as we may by this very act be
accelerating the fatal issue which we desire to avoid.

' It would have been most instructive if Mr. Foster Moore could have given
us a series of pictures of the fundus in cases which he describes as arterio¬
sclerosis and those which he refers to as renal retinitis. These would have
afforded us an opportunity of considering anew whether the appearances in the
two classes of cases could be regarded as distinctive apart from the clinical
picture presented by the physician. He (Mr. Foster Moore) has told us that
the signs which he describes as due to arterio-sclerosis cannot be looked upon
as pathognomonic. Should we not be right to conclude from this that the
appearances in question are common to many forms of disease which give rise
to changes in the peripheral part of the vascular system, such as in the kidney
and in the retina, each of which possesses a highly specialized arrangement of
its terminal vessels ? It will be noted that I have not referred here to cardio¬
vascular changes, for the questions of high blood-pressure and the like involve
quite a different aspect of the case. Dr. Ellis, with his interesting series of
cases, has afforded us valuable material for thought, as he has given us the
benefit of the most recent methods of testing renal efficiency.

I will quote here a passage from the paper by Professor Hugh MacLean,
delivered at the annual meeting of the British Medical Association, published
in the British Medical Journal for December 2, 1922, relating to cardio¬
vascular changes and its effect on prognosis:

“There are many subjects who show but little evidence of marked cardio-vascular
changes, but in whom the renal system is hopelessly inefficient. Conversely, it is not
uncommon to find patients with very marked cardio-vascular changes in whom but
little evidence of renal disease can be ascertained. These points must always be taken
into consideration in estimating prognosis, for, in a general way, apart from such
accidents as cerebral hemorrhage, the outlook in a patient with high blood-pressure
is not so bad if the kidneys are efficient. Indeed, such patients may enjoy comparatively
good health for many years, even with a blood-pressure as high as 200 mm. mercury
or even more. This observation explains the curious cases one occasionally finds
quoted in the literature, in which a history of high blood-pressure of 250 or over,
frequently associated with retinitis and other eye changes, was not incompatible with
the enjoyment of fairly good health for several years.”

The conclusion to be deduced from these researches may be best expressed
in the words of my old teacher, Sir Michael Foster, when he had come to
an end of his lecture on some fascinating physiological problem, told with
convincing force : “ The matter is not yet ripe for any dogmatic statement.'’
In spite of this we still continue to use that most dangerous weapon of
prophecy, which we designate prognosis, in order to foretell the year if not the

Sections of Medicine and Ophthalmology

date of a man’s death. Some of us have been in touch with primitive races
among whom the emotions have more than ordinary influence, and we know
that the mere expectation of death in many cases is sufficient to produce this
result. This condition is not unknown in human life nearer home and it
should prescribe to us supreme caution in the statements which we make
in public or in the secrecy of our consulting rooms. This brings me to the
chief personal contribution which I can make to the discussion on this subject,
mainly from my recent studies in the psychological aspects of health and
disease. A year ago I wrote a paper for the International Ophthalmological
Congress at Washington, which was presented there in April last, on “ Psycho¬
pathology in its Relation to Ophthalmic Practice,” and in this I drew attention
to the close connexion between diseases of the eye and those which were
looked upon chiefly as psychical disorders. Since then I have been developing
the hints which I then put forward in many directions.

I propose to make two suggestions bearing upon the present discussion in
the hope that they may serve as a fruitful germ of thought to others, (l) The
element of cardio-vascular disturbance is one of the essential factors in the
fatal termination in cases such as those we are considering. Without taking
special account of the precise effect upon the pulse or the blood-pressure of
what we may call an emotional trauma, we are all of us aware of the disastrous
results of a condition of panic or passion. The blanching of the skin of
the face in the one case and the reddening in the other indicate the effect
on the peripheral circulation of these emotions, which may be associated with
violent physical manifestations. Thus in the case of panic there may be a state
akin to temporary paralysis, or in passion violent muscular tremors. These may
be said to be attributable to an element of fear, which it is the duty of the
psychologist to investigate. It is contended that phobias of varying amount
are an essential element in advanced cases of renal disease or other serious
illnesses with a reputation for incurability, especially when the severity of the
case appears to be indicated by ocular complications ; and this needs to be borne
in mind.

(2) With regard to the changes in the peripheral circulation, let me assume
that Dr. Batty Shaw’s hypothesis is correct, and that we are dealing with a
toxic process affecting both the kidneys and the retina. The problem which is
always before us is the explanation of the selective action of various toxins
producing changes in the various vital organs. A great deal of evidence is
available to prove the profound influence of suggestion or auto-suggestion upon
local inflammation and vascular disturbances, especially of the skin. It is con¬
tended that this is due to the effect upon the peripheral circulation of psychical
processes acting through the medium of the nervous and circulatory mechanism,
and that suggestions of an unfavourable kind tend to produce morbid vascular
changes. It is impossible in a contribution to a discussion to do more than
suggest the lines upon which inquiry might be conducted, and it is earnestly
hoped that the teaching of modern psychology may be considered in its relation
to these obscure problems of pathology.

Dr. Batty Shaw (in reply) (read by Dr. Izod Bennett).

This discussion has been fruitful in at least one direction, viz., that it has
given an opportunity for a statement of claim to those who believe that there
is a something behind arterio-sclerosis which is not only responsible for the
occurrence of arterio-sclerosis, but which is independently responsible for other

34 Batty Shaw: Arteriosclerosis and Renal Disease

changes such as those met with in the retina when the blood-vessels of that
tissue are altered and for similar changes in the retina when such vascular
change is slight or quite absent; and we must hope that impetus may be given
to those who would look for some agent responsible for both, in the blood
circulating within the vessels.

Important as the result of discussion is, it is but a part of a much larger
question, for all that has been said against the view that arterial disease is
responsible for so-called arterio-sclerotic retinitis may be equally urged against
the view that the contracted kidney is responsible for what is known as
uraemia. It will have struck other members of this audience that with the
exception of five cases out of the twenty-seven tabulated by Mr. Foster Moore,
in which no blood-pressure readings were made, there was only one patient in
whom the blood-pressure was not raised above 150 mm. of mercury, i.e., blood-
pressure was raised in 97 per cent, of the cases. If we believe that the rise
of blood-pressure may result from the occlusion of the lumen of arteries
by endarteritis which has gradually developed and become universal, the
occurrence of hyperpiesis is readily explained, but as I have pointed out, this
obliterative disease of the arteries must be capable of running an unexplainably
fugitive and recurrent course, or we should not see the rapid falls of blood-
pressure or the equally rapid rises of blood-pressure I have figured. If we
believe, as we must be asked to do, that hyperpiesis can result from obliterative
disease of only a part of the arterial tree—for all of Mr. Foster Moore’s cases
of arterio-sclerotic retinitis were free from the suspicion that the renal arteries
at any rate were so diseased as to produce renal disease—we must re-write the
physiology of the vasomotor system. At present we know that if the arterial
system of such a large tract as one leg is blocked by ligature at amputation,
the blood-pressure of the rest of the arterial tree is not raised; adjustment is
made in the vasomotor system and the blood-pressure of the rest of the body
remains normal, as observation has shown. It seems to me that the large
proportion of Mr. Foster Moore's cases show hyperpiesis because there is some
pressor body, or bodies, circulating in the blood-stream.

Dr. Hawthorne objects to the use of qualifications such as “ arterio¬
sclerotic,” “renal,” or “toxic,” on the ground that the problems underlying
this nomenclature have not yet been solved ; but I think it is apparent to all of
us that there is little advantage in speaking of retinitis occurring in arterio¬
sclerosis and retinitis occurring in renal disease, or in toxaemia, for we know
that authorities would still believe that there were retinal changes met with in
arterio-sclerosis entirely dependent upon the arterio-sclerosis—a view so ably
presented by Mr. Foster Moore, and if we speak of retinitis present in renal
disease we should perpetuate the belief that even in these cases the renal
disease actually causes the mischief. If Dr. Hawthorne hesitates to accept my
view that a pre-renal toxaemia is responsible for both the arterial change and
for the retinal change, directly in both cases, on the ground that no one has
yet demonstrated the presence of such agencies, I would suggest instead of the
term “ toxic retinitis,” “ hyperpiesic retinitis,” for hyperpiesis was present in
nearly all of Mr. Foster Moore’s cases of so-called arterio-sclerotic retinitis;
and I can state that in eleven cases which formed part of my recent study,
retinitis was present and they were all cases of hyperpiesis. I have given
reasons elsewhere why I think such great confusion has arisen in the
symptomatology of renal disease, and have tried to show how all such
difficulties could be resolved if, instead of expecting to find regularly a
well-defined picture of kidney disease behind each well-defined clinical picture,

Sections of Medicine and Ophthalmology

we gave up the position and rather looked to the blood as a source, not only of
the clinical manifestations, but of the kidney change. This point of view is
brought out by Dr. Goldschmidt in his clinical report (p. 23) of a form of disease
which though not identical with that under discussion is closely allied to it.

Mr. R Foster Moore (in reply).

It is clearly impossible, in the short time remaining, to touch upon more
than a few of the points which have been raised by the various speakers
in this debate.

I do not hesitate to agree with Dr. Batty Shaw that retinitis may be caused
by toxaemia, as in the retinitis of pregnancy instanced by Mr. Fisher, and I
would add parenchymatous nephritis in general; but, on the other hand, it
cannot be denied that retinitis may occur from causes which are local in the
retina, as for example, the star figure which may accompany papilloedema, so
that it is at least not unreasonable to suppose that retinitis may be caused by
the local vascular disease.

In renal retinitis there are, I believe, two factors at work, the one a toxic
factor, which manifests itself by the “ cotton-wool ” patches, which, histo¬
logically, are found to be due to fibrinous exudate which may infiltrate all
the retinal layers ; and the other a vascular factor, which manifests itself by
the presence of exudate having the ophthalmoscopic characters we have
described in addition to evident changes in the vessels, and which is due to-
small areas of hyaline degeneration in the external molecular layer of the
retina. The former is seen in parenchymatous nephritis, the latter in arterio¬
sclerotic retinitis, and I believe both these factors may be concerned in varying
degree in renal retinitis.

I believe, then, that the changes in the retina in arterio-sclerosis to which
the term “ retinitis ” may be applied are immediately due to the impaired
circulation in the retina consequent upon the local disease of the vessels, but
I should by no means be willing to dispute that this disease is in its turn
dependent upon a toxaemia, whether of endogenous or exogenous origin. I have
referred to this point in a previous paper. 1

With regard to the immediate lesion which is responsible for haemorrhages
in the retina, I do not suppose they are due to rupture of large vessels, but
imagine they are due to diapedesis from the capillaries, owing to the impaired
nutrition of the endothelium resulting from defective circulation, and perhaps
to changes in the blood. I believe that in these cases the blood-pressure in
vessels of the size of the central retinal artery is less than the normal, even
though the pressure in the brachial artery is perhaps 250 mm. of mercury ;
I suspect, too, that the retinal haemorrhages which are so frequent in the
blood diseases come about in the same way, through impaired nutrition of
the capillary walls.

I was interested in Mr. Bardsley’s important observation that the “ copper-
wire M appearance of arteries may disappear ; such an observation is outside
my own experience.

With regard to Dr. Hawthorne’s remarks, we know what a terminological
purist he is, but he is less of a purist when he tells us that the differenti¬
ation between renal and arterio-sclerotic retinitis is no more than guess
work !

1 Quart. Jouni. Med., 1917, x, p. 11.

36 Foster Moore : Arteriosclerosis and Benal Disease

I was very glad to find Dr. Gaskell so emphatic in his belief in a primary
disease of the vessels as quite distinct from renal disease. I do not hesitate to
agree with Mr. Leighton Davies that arterio-sclerotic retinitis cannot in all
cases be sharply differentiated from renal retinitis. I thought I had protected
myself against Mr. Mayou’s criticism by pointing out that I was using the
term “ retinitis 99 in the sense that it is used in renal and diabetic retinitis;
it is not a good term, but it is hallowed by long usage, and would, I fear, be
difficult to dislodge; I wish Mr. Mayou would supply us with a better term—it
is badly needed.

With regard to Dr. Newton Pitt’s remarks, I do not think the haemor¬
rhages are due to the lodgment of emboli; they are different in type from the
haemorrhages which are so frequent in the retina in infective endocarditis, and
which I presume are indeed due to emboli.

I was glad to hear that Dr. Feiling found, in agreement with my own figures,
that 60 per cent, of his cases of retinitis in arterio-sclerosis were unilateral;
this alone is surely a fact which weighs heavily against the view that toxaemia
is the direct cause of the retinitis; he mentions that fifteen of his twenty-five
cases were in females ; this preponderance of females has been commented upon
by Nettleship, Gunn and Adams and the fact of its occurrence is borne out by
my own cases.

Retinal detachments are not rare in severe renal retinitis if they are
specifically looked for up to the time of death ; I refer to extensive bilateral
detachments, and not to a collection of exudate under the retina which is
of still more frequent occurrence in histological specimens, but is not to be
made out with certainty by the ophthalmoscope. These conspicuous detach¬
ments are often overlooked from the fact that the physician, having ascertained
the existence of retinitis, does not always continue with periodic examinations
up to the time of death ; I have seen two of these cases within the last six
months, and was able to collect thirteen of them in two years at St.
Bartholomew’s Hospital.

PROCEEDINGS

OF THE

ROYAL SOCIETY OF MEDICINE

EDITED BY

Sir JOHN Y. W. MacALISTER

UNDER THE DIRECTION OF

THE EDITORIAL COMMITTEE

VOLUME THE SIXTEENTH

SESSION 1922-23

SECTION OF ORTHOP EDICS

LONDON

LONGMANS, GREEN & CO., PATERNOSTER ROW

1923

Section of ©rtbopfc&tco

OFFICERS FOR THE SESSION 1922-1923.

President —

T. H. Openshaw, C.B., C.M.G., M.S.
Vice-Presidents —

E. Laming Evans, C.B.E., E.R.C.S.

Sir Robert Jones, K.B.E., C.B., F.R.C.S.
E. Muirhead Little, F.R.C.S.

lion. Secretaries —

W. Rowley Bristow, F.R.C.S.

W. T. Gordon Pugh, M.D.

Other Members of Council —

D. McCrae Aitken, F.R.C.S.

Aslett Baldwin, F.R.C.S.

A. S. Blundell Bankart, M.Ch.
Naughton Dunn, M.B.

R. C. Elmslie, O.B.E., M.S.

H. A. T. Fairbank, D.S.O., O.B.E., M.S.
M. Fitzmaurice-Kelly, F.R.C.S.

P. Maynard Heath, M.S.

W. H. Ogilvie, M.Ch.

Representative on Library Committee —

E. Laming Evans, C.B.E., F.R.C.S.

Representative on Editorial Committee —

H. A. T. Fairbank, D.S.O., O.B.E., M.S.

SECTION OF ORTHOPAEDICS

CONTENTS.

October 3, 1922.

T. H. Openshaw, C.B., C.M.G., M.S. page

President’s Address: Traumatic Spondylitis... ... ... ... 1

November 7, 1922.

H. A. T. Fairbank, D.S.O., F.R.C.S.

Ischaemic Paralysis ... ... ... ... ... ... 11

P. Maynard Heath, F.R.C.S.

(1) Traction Fracture of the Small Trochanter ... ... ... 12

(2) Subluxation of the Inner End of the Right Clavicle ... ... 12

W. T. Gordon Pugh, M.D., B.S.

Fracture of the Small Trochanter ... ... ... ... ... 12

D. M. Aitkbn, F.R.C.S.

Osteo-chondritis of the Hip . .. ... ... ... ... IB

W. Rowley Bristow, F.R.C.S.

Transplantation of the Hamstrings... ... ... ... ... 13

R. C. Elmslib, O.B.E., F.R.C.S.

Congenital Deformity of the Upper Limbs and Feet ... ... 13

Paul Bernard Roth, F.R.C.S.

Injury to Epiphysis of Left Acromion Process ... . . ... 14

E. Laming Evans, C.B.E., F.R.C.S.

Tendon Transplantation for Talipes ... ... . ... 14

December 5, 1922.

DISCUSSION ON OPERATIVE TREATMENT OF DISLOCATED HIPS,
CONGENITAL AND PATHOLOGICAL.

Mr. H. A. T. Fairbank (p. 16), Mr. R. C. Elmslib (p. 24), Mr. W. II.
Trbthowan (p. 24), Mr. D. M. Aitken (p. 24), Mr. A. B. Bankart (p. 25),

Mr. R. A. Ramsay (p. 25), Mr. T. P. Noble (p. 25), Mr. H. A. T. Fairbank
( reply) (p. 25).

Acton Davis, F.R.C.S.

Case of Multiple Exostoses ... ... ... ... ... 26

February 6, 1923.

R. C. Elmslie, O.B.E., F.R.C.S.

(1) Case of Hsemophilic Arthritis of the Knee ... ... ... 27

(2) Case of Arthritis due to Dental Sepsis diagnosed and treated as

Tuberculosis ... ... ... ... ... ... ... 28

Paul Bernard Roth, F.R.C.S.

Two Cases of Kohler’s Disease ... ... . . 28

H. A. T. Fairbank, D.S.O., F.R.C.S.

Unusual Form of Syndactyly

Conten ts

I>. M. Aitken, f.r.c s. vwe

Traumatic Osteo-arthritis of Neck treated by Bone-graft ... ... HO

Maynard Heath, M.S.

Late Result of Beef-bone Graft of Humerus... ... ... HQ

Walter Gripper, M.B.

A Case of Congenital Subluxation of Humeri ... ... 30

W. T. Gordon Pugh, M.B., B.S.

Two ( ases of Fractured Neck of Femur in Training-ship Boys ... 31

March 6 , 1923 .

DISCUSSION ON THE OPERATIVE TREATMENT OF SPASTIC

PARALYSIS.

Mr. A. S. Blundell Bankart (p. 38), Mr. T. H. Openshaw (President) (n. 87).
Dr. George Riddouh (p. 87), Mr. E. Muirhead Little (p. 37), Mr. E. Laming
Evans (p. 38), Mr. H. A. T. Faihhank ip. 38), Mr. Rocyn Jones (p. 39), Mr.
Gordon Pugh fp. 39), Mr. W. Rowley Bristow (p. 40), Dr. A. Feiling (p. 40),
Mr. R. C. Elmslie (p. 40), Mr. Naughton Dunn (p. 41), Mr. P. Jknnkr
Vkrrall (p. 41), Mr. Bankart (in reply) (p. 41).

April 17, 1923.

C. Max Page, D.S.O., F.R.C.S., M.S.Lond.

Font Cases of Flexion Contracture of the Forearm treated by a Muscle-
sliding Operation

Paul Bernard Roth, F.R.C.S.

(1) Case of Renal Dwarfism shown after Operation for Genu Valemn ...

(2) Case of Ocular Torticollis ... 5

B. Whitchurch Howell, F.R.C.S.

Case of Snapping Hip
H. A. T. Fairbank, D.S.O., M.S.

(1) Case of ? Charcot’s Knee

(2,/ Caseof Dislocation of Patella outwards, secondary to Osteomyelitis
of Femur

G. Perkins, M.Ch., F.R.C.S.

Case of Pseudo-Coxa Igin in an Adult

4.1

May 1, 1923.

R. C. Elmslie, O.B.E., F.R.C.S.

Case of Infcraeapsular Fracture of the Neck of the Femur ... ... 49

Paul Bernard Roth, F.R.C.S.

Case of Osteitis Deformans ... ..49

B. Whitchurch Howell, F.R.C.S.

Case of Tendon Transplantation ... ... 50

W. H. Ogil vie, M.S.

(1) Case of Renal Dwarfism ... ... *71

peeimen of Synostosis of Phalangeal Joint ? Congenital in Origin ... M

The Society does not hold itself in any way responsible for the statements made or
the views put forward in the various papers.

John Ha i k, Sons At Daniklhson, Ltd., ss-!)], Groat

TitohliHd Stro»*t, London, W. 1.

Section of ©rtbopreMcs.

President — Mr. T. H. Openshaw, C.B., C.M.G., M.S.

Traumatic Spondylitis:

PRESIDENT'S ADDRESS.

By T. H. Openshaw, C.B., C.M.G., M.S.

On assuming the Chair as President of the Orthopaedic Section of the Royal
Society of Medicine, my first duty is to express my sincere thanks for the
honour conferred upon me by the Council.

My next duty is to congratulate the Orthopaedic Section on having had such
a distinguished, energetic and tactful President as Mr. Laming Evans, to whose
energy and courtesy we owe the fact that this Section has been recognized as a
full Section of the Royal Society of Medicine.

My next duty is to call the attention of the members of this Section to the
fact that the British Orthopaedic Association, under the distinguished Presi¬
dency of Sir Robert Jones, will hold its meeting in this building on the 20th
and 21st of this month. I trust every member here will make a point of
attending the meeting.

The status of an orthopaedic surgeon has materially advanced of late; there
was a time when it was as much as anybody’s reputation was worth to be known
as an orthopaedic surgeon !

The scope of orthopaedic surgery has been considerably enlarged during the
war, but there are still many subjects connected with it upon which a dis¬
cussion is advisable, and in which uniformity of treatment should, if possible,
be carried out. It is not conducive to the welfare of the patient or to the
dignity of the profession that two consultants should give diametrically
opposite opinions as to whether a certain operation should be done or not.

It is, I think, advisable that, so far as possible, the treatment of any
particular condition should be determined and generally accepted. Take, for
instance, the question of hammer-toe. Some surgeons advise amputation,
others excision of the interphalangeal joint, others excision of the head of the
proximal phalanx, and others division of the flexor tendon and splinting. Those
of us who know what can be done usually, I think, adopt the last method, but
it would be well if there could be a universal consensus of opinion as to its
advisability.

Again, take the question of amputation of the toes. If, for any reason,
the great toe is so badly damaged that it has to be amputated, is it or is it
not advisable to amputate all the other toes ? Or, conversely, if the four
lesser toes have to be amputated, is it or is it not advisable that the big
toe should be amputated also? I am one of those who believe that the
great toe should be amputated, but I may be in a minority. The question,
I think, should be discussed, and some agreement reached if possible.

Again, many feet have been amputated because a bullet which passed
through the tarsus has produced enormous exfoliation of new bone in the
sole, pressing on the digital nerves, and thus rendering progression impos¬
sible. No apparatus or support enables the patient to walk with comfort.
What should be done for these cases ? I have several times turned a triangular

N—OK 1 f October 3,1922.

2 Openshaw : Traumatic Spondylitis

flap outwards to the outer border of the foot, removed the plantar fascia, and,
along the external intermuscular septum, got down to the bony outgrowth,
which I have successfully chiselled off, so saving the patient’s foot and
enabling him to walk with comfort.

This evening I am bringing before you the subject of “ Traumatic Spondy¬
litis, or Fracture-dislocation of the Spine.” I do not propose to deal particu¬
larly with those cases of fracture-dislocation of the spine which have resulted
in severe compression or laceration of the spinal cord. In these cases there is
complete loss of motion and sensation below the injured spot, and the diagnosis
is easy. There are many other cases, however, in which the spinal cord is not
so compressed or lacerated as completely to destroy transmission of all nervous
impulses. In these cases the injury to the vertebral column may have resulted
only in compression and laceration or irritation of one or more nerves. When
this condition occurs in the cervical region, the patient will usually complain of
an impairment of power of mobility in the neck, a diminution of free range of
movement in the neck, pain on certain movements, and sometimes a projection
of one or other of the cervical vertebrae. When an X-ray photograph is taken
of this condition, it may show a definite backward displacement of one
vertebra only; or the whole of the neck with the particular vertebra may be
displaced backwards, one or other of the articular or other processes may be
broken, and irregularity of adjacent surfaces result.

I pass round the X-ray prints of a patient, K., who fell from his horse in
the South African War, and was laid up for some months, but it was not
until he hurt his back in 1916 that the fracture of the neck was diagnosed.
The X-ray print shows definite increase in the intervertebral space between
the fifth and sixth cervical vertebrae, with a compression, subluxation and
irregularity of the fifth cervical vertebra. At the present time this patient has
no symptoms which point to his cervical injury.

I also show the X-ray print in the case of a patient, N., in which is seen a
dislocation of the fifth cervical vertebra backwards for a distance of three-
eighths of an inch. The patient fell from his horse in India about nine
months ago, and has since suffered from gradually increasing paralysis of the
forearm muscles of the right arm, and of the shoulder muscles. The grip
power in his right arm had become so feeble as to render him unfit for duty,
and he returned to England. When seen by me in May, 1922, he had absolute
loss of power of motion in the neck, which was held stiffly, marked wasting
of the right arm, and, particularly, of the muscles of the forearm and shoulder.
In consultation with Sir James Ihirves Stewart I wrenched the neck under
anaesthesia, and as is shown by these two prints which I pass round, the dis¬
placed vertebra has been partially restored to its normal position. Some days
after the manipulation he had some loss of power in the other arm, but this was
transient, and he has also recovered from the original paralysis of the right
arm. This is the only time that I have ever wrenched a neck vigorously with
the idea of replacing the cervical vertebrae in position, and it is satisfactory
to note that the operation has been attended by a complete cure of the patient.
The patient’s neck can now be moved in normal directions, though the range
of movement is still somewhat restricted. The weakness of the right arm,
however, has almost completely disappeared, and the patient’s grip is equal
on the two sides.

The usual form of treatment to be adopted in cases of fractured cervical
spine, not immediately fatal, should be, I think, the wearing of an accurately-
moulded leather collar, so as to prevent the spine from moving, and so
stretching and irritating particular nerve trunks.

Section of Orthopaedics

I show the X-ray photograph from the case of a patient, T., who was
hit in the back of the neck in an aeroplane crash, and it shows a separation of
the fifth and sixth cervical vertebra. The patient complained of acute pain
in the right breast at one spot, about 5 in. below the clavicle and 2 in. from
the middle sternal line, when he bent his head to the left, and of the same
acute pain in the left breast when he turned his head to the right, and
of pain in both breasts when he bent his head forwards. These pains have
completely disappeared as the result of wearing a leather collar.

Some two years ago a patient came to me at the London Hospital with
the following history: She had just got out of bed, became giddy, and fell
backwards, striking her head on the edge of an iron bedstead. She was laid
up for a few days, and then noticed that the right arm was becoming weaker
and increasingly painful. The pain persisted, and the loss of power progressed.
An X-ray photograph was taken, and showed dislocation of the neck at the
fifth cervical vertebra. With the idea of replacing the vertebra and securing
it in position, I made an incision over the middle line of the neck, and wired
the two laminae together. The wire was screwed up and left in, and power in
the right arm steadily returned; after four months I removed the wire. I
regret to say that the weakness of the arm is again returning, and I presume
some further operative treatment will be necessary. To wire the laminae
together in a severe case of displacement of the lower cervical vertebra is, I
believe, the best method of securing and maintaining them in position. In my
opinion the wire should be left in situ permanently.

We have therefore at our disposal, so far as the neck is concerned, three
methods of treatment: (a) By manipulation to wrench the vertebra back into
its place, (6) to put up the head and neck in plaster of Paris for a time, and
afterwards to prescribe a properly fitting leather collar; ( c ) to procure the
proper apposition of the vertebra by means of a wire passed round the
laminae.

In the dorsal and lumbar regions the diagnosis of fracture-dislocation may
present some difficulty. The symptoms may be pain, tenderness, rigidity,
irregularity of the spinous processes and deformity, angular curvature, kyphosis,
or lateral curvature, and hyperasthesia of the intercostal nerves. The pain may
be referred along the intercostal nerves (the so-called “ girdle ” pains), or along
the lumbar nerves, or along the sciatic nerve, and may lead to a mistaken
diagnosis of rheumatism, lumbago, or sciatica. It may be worse on movement,
and often steadily increases in severity. There will generally be found some
tenderness on pressure upon the spinous processes of one or two vertebra.
Rigidity is usually located at the injured parts, and may extend upwards or
downwards over the space of two or more vertebra. When the patient bends
forward, the spinous processes do not separate in a normal manner. It must be
remembered that the pain and rigidity do not necessarily commence at once, and
that the condition of the back may be overlooked, owing to the presence of another
injury. Some irregularity of one or more of the spinous processes is usually
to be seen, or there may be a kyphotic or lateral curvature. Hyperaesthesia
may mark out exactly the course of the intercostal nerve which corresponds
to the seat of the fracture-dislocation, and even in slight cases of irritation the
area of skin supplied by the dorsal branch of the corresponding branch of the
intercostal nerve will be hyperasthetic. This hyperasthesia, if present, is a
most valuable sign. It demonstrates the presence of neuritis in the inter¬
costal nerve, and as the exact area of skin supplied by this nerve is beyond
the knowledge of a malingerer, its precise demarcation is a proof of the
genuineness of his symptoms.

4 Openshaw: Traumatic Spondylitis

In other cases, where the diagnosis is doubtful, or where an injury of the
hack is suspected, an X-ray photograph should be taken. Where there is
a history of pain, rigidity, and a hyperaesthetic area, an X-ray photograph
is imperative. X-ray plates must be clear , or they are worse than useless.
Over and over again I have had patients with rigid backs and hyperaesthesia,
and have been told that they had been X-rayed, and that the X-ray plate
showed nothing. The photographs should betaken stereoscopically, and should
be examined in the stereoscope. It is only in this way that slight changes
can he seen, or the absence of any change be proved.

Fig. 1.— F.

The detection of malingering is essential. b Symptoms of pain and rigidity,
and altered gait, are sometimes perfectly simulated, but it does not fall within
the ability of a malingerer to mark out exactly the patch of skin which should
be hyperaesthetic when the dorsal branch of an intercostal nerve is the subject
of neuritis or irritation.

Tiie X-ray plate may show the following deviations from the normal :
(a) Compression of the body of the vertebra anteriorly or laterally; (b) wedge
formation of the vertebra; (c) obliquity of surfaces ; (d) irregularity of adjacent
surfaces of two or more vertebra!; (e) gaping of front part of intervertebral
space : (/) lipping, usually of the anterior edges, of the upper or lower surface:

Section of Orthopaedics

(g) absorption of bodies centrally ; ( h) kyphosis, separation of ribs ; (i) angular
curvature; (;) ankylosis and synostosis; (fc) lateral deviation; (Z) rupture of
supra- and interspinous ligament; and most of them are ‘shown in the plates
exhibited. ’ICXICi

X-ray plates are exhibited from cases of the following patients, and prints-
from some are reproduced :—

F., thrown from his horse whilst steeplechasing in 1908; struck shoulders and back
of head ; was laid up for six months ; gradually recovered. He went out to the Front

Fig. 2.—L. L.

in the war; fell into a trench in 1915 and wrenched his back; was laid up with
continual pain and rigidity until seen by me in 1916 ; wore a corset for two years.
Complete recovery. X-ray plate shows a wedge formation of the tenth dorsal vertebra,
owing to compression of the anterior half of the body (fig. 1, p. 4).

K. was buried in 1916 by a falling dug-out. When first seen by me in 1918 he
complained of gradually increasing unsteadiness of gait. Knee-jerks normal; weakness
of legs and definite hypenesthesia of dorsal branches ; was trephined by another surgeon
with some benefit, but still has weakness of legs and incoordination of leg muscles*
X-ray plate shows lipping of the bodies of the eighth, ninth and tenth dorsal vertebra?,

*6 Openshaw: Traumatic Spondylitis

with wedging of the ninth dorsal vertebra. This patient also has a subluxation of the
cervical spine,

N., injured back while steeplechasing in 1912; was laid up for some months.
In 1915 fell into trench and wrenched his back again. Was invalided home. Had
continuous pain until put into corset by me in 1915 : wore corset thirty months.
Complete recovery. X-ray plate shows irregularity of the surfaces of the tenth dorsal
vertebra.

Fig. 3.—C.

L. L. was thrown from his horse in 1915 ; complained of pain and weakness in the
back ; there was irregularity of the dorsal spines; had continuous pain for one year,
until put into leather corset. Complete recovery after wearing corset for eighteen
months. X-ray plate shows wedging of the tenth, eleventh and twelfth dorsal and first
lumbar vertebne, and well marked kyphotic curve and irregularity of the surfaces of
these vertebne (fig. 2, p. 5).

G. gives a history that when shot in 1915 he fell backwards into a trench. Has
a scar over the external occipital protuberance. No symptoms from the head injury or
from the thigh at the present time. Has had pain in the back ever since he was shot.
X-ray plate shows definite kinking to the left of the eleventh and twelfth dorsal

Section of Orthopaedics

vertebrae, separation of the eleventh and twelfth ribs, lipping and synostosis of the
eleventh and twelfth dorsal and first lumbar vertebra 1 , and compression of the anterior
edge of the eleventh dorsal vertebra, with marked dorso-lumbar kyphotic curve.

C. was buried by a shell in 1917 ; has complained of pain in back ever since.
X-ray plate, taken in 1920, shows definite lipping of the second, third and fourth
lumbar vertebra; (fig. 8, p. 6).

T. T. crashed in an aeroplane in 1917 ; had concussion for twenty-four hours, and
wrenched his back at the same time; complains of persistent headache and pain in the
back ever since the date of the injury. X-ray plate shows absorption of the central
part of the bodies of the tenth and eleventh dorsal vertebrae (fig. 4).

Fig. 4.—T. T.

In all these cases a spinal corset has been worn with marked benefit, and
some are completely cured already.

The cases most difficult to diagnose are those of injury to the lumbar spine.
In the neck there will be definite symptoms referred along one or more nerve
trunks. In the dorsal region there will be some deformity. In the lumbar,
and particularly in the lower lumbar region, however, there will rarely be
deformity. The hyperoesthetic area may be confused, and the pain may
easily be mistaken for sciatica, and the diagnosis of rheumatism may quite
reasonably be made.

Openshaw: Traumatic Spondylitis

The following are cases of injury to the lower lumbar spine:—

C. was struck on the back by a hoist of coal in 1917. Had continuous pain in the
back until 1921, when the diagnosis was first made, and he was ordered to wear
a corset. Ever since the case was diagnosed and the corset supplied, he has been free
from pain. X-ray plate shows opening of the front part of the intervertebral space
between the third and fourth, and fourth and fifth lumbar vertebrae, with lipping of the
adjacent edges of these vertebrae, also ankylosis of the fourth and fifth lumbar vertebrae
on the right side.

Fig. 5.—T.

T. was buried in 1916. Was first seen by me in 1920. X-ray plate showed a
definite gap to the right between the first and second lumbar vertebrae; the second
lumbar vertebra is a little compressed from above downwards on its left side, so as to
make it wedge-shaped; the second and third lumbar vertebra) are smashed together,
and both are compressed on their left edge ; the upper edge of the fourth lumbar
vertebra is very oblique; the lower edge of the fourth and the upper edge of the fifth
lumbar vertebrae are normal (fig. 5). There is no deposit, and no erosion pointing to
inflammation or to long-standing disease.

H. was buried in 1916. Was under medical treatment with pain in lower lumbar

Section of Orthopaedics 9

and gluteal regions until 1921. X-ray plate shows synostosis of the fourth and fifth
lumbar vertebrae (fig. 6).

B. was thrown from a mule in 1916 ; unconscious for twenty-four hours. X-ray
plate taken in 1922, shows erosion and irregularity of the adjacent surfaces of the
eleventh and twelfth dorsal vertebra, synostosis of the fifth lumbar vertebra with
the sacrum on each side, synostosis of the fourth and fifth lumbar vertebra on each
side—the right side being most involved—and marked obliquity of the fourth lumbar
vertebra (fig. 7).

H. was buried in 1916. Has had pain in the back ever since. X-ray plate shows
obliquity and compression of the fifth lumbar vertebra. Was first seen in 1921, and
has worn a corset for one year with distinct benefit, but has not yet free mobility of
the lumbar space.

Fig. 6.—H.

Even when an X-ray photograph seems to show something abnormal
about the fifth lumbar vertebra, some surgeons are inclined to say that such
abnormalities are congenital. The fifth lumbar vertebra is undoubtedly liable
to variability, but obliquity of surfaces and synostosis are not congenital
deviations from the normal. It has long been an axiom that effects of injury
are manifested where a movable portion of the spine joins a fixed one. It is
intelligible, therefore, that injury should take place, not only near the twelfth
dorsal vertebra, but also near the fifth lumbar vertebra.

As regards treatment, the spine should be put at rest:—

Openshaw: Traumatic Spondylitis

(1) In the neck: (a) By a leather or felt collar ; ( b ) by wiring (the wire
should be left in).

(2) In the back : (a) By recumbency (for severe symptoms, e.g. paralysis) ;
( b ) by a leather corset with steels and arm supports ; ( c ) by wiring (for
increasing kyphosis).

(3) In the lumbar region : (a) By a leather corset; ( b ) by lacing the
spinous processes together by silver wire.

As regards prognosis :—

(1) Suppuration is rare, unless there is some suppurating open wound
elsewhere. In not one of the cases shown was there suppuration.

Fig. 7.—B.

(2) The pain diminishes quite quickly after the spine is immobilized.

(3) The hyperaesthesia quickly begins to diminish in extent of area.

(4) The cure is slow : eighteen to thirty months must be allowed.

My object in bringing these cases before you is first to emphasize the
importance of examining for hyperaesthetic areas, and of judging by their
position, and by the accuracy with which they are marked by the patient,
whether the symptoms of pain and rigidity are genuine or not, and secondly to
point out the advisability of giving due importance to the statement that the
patient has been buried, and of putting the spine at rest in a corset as soon as
possible.

Section of ©rtbopaet>ic0.

President—Mr. T. H. Openshaw, C.B., C.M.G., M.S.

Ischaemic Paralysis.

By H. A. T. Fairbank, F.R.C.S.

The case is that of a boy, aged 9, who sustained a fracture of the lower
end of the right humerus in December, 1921. No history of the treatment
then received is available. He was admitted to the Hospital for Sick Children
in January, 1922, with typical ischaemic contracture of the right forearm.
There was flexion of the wrist and interphalangeal joints with some hyper¬
extension of the metacarpo-phalangeal joints, all of which were stiff with only
a small range of painful movement. The long flexors of the hand were just
acting but there was no power in the interossei. The general nutrition of the
hand was very defective and the skin purple. Sensation to cotton wool was
lost over the whole hand on both aspects and to pin-prick over the same area,
except over the hypothenar eminence and the ulnar side of the dorsum.
Radiograms showed an old supracondylar fracture in very bad position. Only
10° of movement, from 90° to 100°, were possible at the elbow-joint ; there
was a scar apparently from a deep pressure sore on the anterior aspect
of the forearm. Treatment by gradual stretching and physio-therapy has
produced considerable improvement; but there is still anaesthesia in part of
the median nerve distribution, and the median intrinsics remain almost
completely paralysed; while movements at all the joints are defective, and
there is only slight power in the long flexors. Opinions are invited as to
whether or not the median nerve should be explored.

DISCUSSION.

Mr. W. R. Bristow thought exploration of the median nerve should certainly be
carried out, with the object of obtaining a return of the valuable median sensation
in the hand. The physiological division of the nerve was probably in the region of its
muscular branches to the pronator radii teres and long flexors, so that little could
be done to secure a return of muscular power. Mr. Bristow also showed sections
illustrating the differences in the changes which took place in muscle: (a) In a
peripheral nerve lesion, and (6) in ischaemic contracture.

Mr. Faul Bernard Roth suggested operating on the bony, deformity first, since
in his experience of these cases the deformity was often responsible for the paralysis—
the brachial artery and median nerve being stretched over the bony projection. If this
were done the nerve might recover.

Mr. Fairbank (in reply) said he preferred exploration of the nerve. For the bony
deformity at this late stage he was content to perform a simple osteotomy.

Mh—Ob 1 [November 7, 1922.

12 Heath: Traction Fracture: Subluxation; Pugh: Fracture

Traction Fracture of the Small Trochanter.

By P. Maynard Heath, F.R.C.S.

SKIAGRAMS are shown of a boy, aged 15, who slipped off his bed and
landed on the floor on his buttocks. He immediately experienced great pain
on the front and inner side of his right thigh and found he could not raise his
right leg. , There was no deformity, but active flexion of the hip-joint was
impossible either when lying or standing. In walking the leg is swung
forwards. Attempts to flex the hip cause pain shooting down the inner side
of the thigh. There is tenderness behind the great trochanter and also in
Scarpa’s triangle on deep palpation. X-rays reveal a fracture of the small
trochanter with very little separation. No retentive apparatus has been
employed, and the boy has returned to school, where he takes things easily.
He is now (five months after the accident) playing Association football, but
there is still some wasting of the thigh and buttock, Ludloff’s sign (inability
to flex the thigh when sitting, with deficient flexion, only about 30°, when
lying down) is still present. This is a rare condition, this case being the
twenty-eighth recorded.

Subluxation of the Inner End of the Right Clavicle.

By P. Maynard Heath, F.R.C.S.

The patient, a man aged 30, gave no history of direct injury, but the
condition was thought to have occurred during the unaccustomed exercise
of bowling. The swelling has not altered since first observed last June.
Examination shows a prominence of the inner end of the right clavicle,
and X-rays reveals no enlargement of the bone. I ask for suggestions
as to treatment.

Mr. A. H. TUBBY said he had had a similar case in a man aged 55, and he agreed
that trealanent presented a difficult problem. In his case he had eventually operated
and scraped out a quantity of gelatinous material which proved on microscopic
examination to be thyroid tissue. There was no evidence of a growth elsewhere.
For Mr. Heath’s case he suggested exploration if ordinary treatment by counter¬
irritation failed.

Fracture of the Small Trochanter.

By W. T. Gordon Pugh, M.D., B.S.

SKIAGRAMS are shown from a boy, aged 14, who had previously been under
treatment for acute osteomyelitis of the lower ends of both femora and of the
right tibia, from which he made a good recovery. He was discharged with good
movement. In July, 1921, three months after discharge, he was readmitted
to Queen Mary’s Hospital with a history that while running and in the act of
lifting the left thigh he heard a crack and felt a severe pain in the inner part
of the left groin. There was no deformity or shortening, but all thigh move¬
ments were slightly limited and painful. X-rays revealed a fracture of the
lesser trochanter, which united in the displaced position after treatment by
flexing the knees over pillow's. When last seen five months later there was
full movement.

Section of Orthopaedics

Osteo-chondritis of the Hip.

By D. M. Aitken, F.R.C.S.

Radiograms are shown of three different stages of this disease in three
members of the same family: T. M., aged 7, male, A. M,, aged 13, and R. M.,
aged 20, females. In addition to the hip condition A. M. has a slight luxation
forwards of the upper ends of both radii, and R. M. has developed considerable
limitation of movement of both radii associated with luxation of the heads
of the radii and scoliosis. X-ray plates of the last show arthritic changes
of the head of the femur in addition to some mushrooming.

DISCUSSION.

Mr. FAIRBANK suggested that the cases were of arthritis rather than of true
pseudo-coxalgia. The appearances in the X-rays suggested to him an ulcerative or
absorptive arthritis.

Mr. Laming Evans inquired whether there were any signs of rickets in the three

cases.

Mr. Aitken (in reply) said that there was no evidence of rickets in any of the
cases. While he agreed that in the eldest patient there were definite arthritic
changes superimposed on the original osteochondritis, he adhered to his original
diagnosis.

Transplantation of the Hamstrings.

By W. Rowley Bristow, F.R.C.S.

The patient suffered from a gunshot wound of the thigh in 1918. He had
a large scar on the front of the thigh ; the quadriceps extensor femoris was
not functioning; and he was unable to extend the knee. The biceps and some
of the inner hamstrings were transplanted to the front, and attached to the
patella at a hospital in the country. The patient states that he is worse as
result of this operation, for although he can strongly extend the knee-joint he
can no longer flex it more than a few degrees on walking. He is unable to
flex the knee against gravity except when lying on his face, when 15° to 20° of
flexion are possible—the transplanted muscles and the remaining hamstrings
both acting strongly. The vastus internus, which has recovered, remains flaccid.
It therefore appears that the transplanted hamstrings still act with the flexors.
Dr. J. Sainsbury (in charge of the Physical Training Department at Shepherd’s
Bush) thinks further treatment by physical means, by which the patient has
already been treated for nine months at another hospital, unlikely to be
successful. While there is undoubtedly a mental factor in the case, I am
inclined to think the only available treatment is to undo the transplant.

Mr. FAIRBANK, Mr. ELMSLIE, Mr. Pugh and others, agreed that the transplant
should be undone.

Congenital Deformity of the Upper Limbs and Feet.

By R. C. Elmslie, O.B.E., F.R.C.S.

The patient came under my care in 1922. He then had bilateral talipes
squirms with much wasting of the legs. The hands were held fully pronated,
with the elbows extended and wrists flexed. There was marked wasting of the

14 Roth: Injury to Acromion ; Evans: Tendon Transplantation

shoulders, arms, and forearms, but there was some power in the flexor and ex¬
tensor muscles of the forearms and hands. I treated the left foot (which was
more severely affected) by osteotomy of the fibula and of the neck of the
astragalus, followed by wrenching and plaster. The hands were manipu¬
lated and extended by splinting. An arthroplasty was performed on the right
elbow.

I still have the question of performing an arthrodesis of the shoulder
under consideration, but up to the present I am concentrating my efforts upon
attempting to get the patient’s hands into such a position that he will be able
to feed himself.

Injury to Epiphysis of Left Acromion Process.

By Paul Bernard Roth, F.R.C.S.

The patient, a girl, aged 16, complains of pain in the left shoulder, which
has lasted intermittently for four months, and is relieved by resting the arm.
On examination at hospital the tip of the acromion was found to be
acutely tender, there was marked limitation of abduction, and all movements
of the shoulder produced pain. X-ray examination showed partial fusion of
the left acromial epiphysis with displacement upwards, whereas on the
right side the epiphysis remained distinct from the diaphysis. The patient
has improved with rest to the arm in a sling, but pain recurs on her using
the arm contrary to advice.

Tendon Transplantation for Talipes.

By E. Laming Evans, C.B.E., F.R.C.S.

The patient is a girl, aged 9, in whose case I have performed a tendon
transplantation for paralytic talipes equino-varus. Treatment by manipula¬
tions and instruments having failed, I have transplanted the tibialis anticus
tendon to the base of the fifth metatarsal, with a satisfactory functional
result.

Section of (Prtbop&btce.

President—Mr. T. H. Openshaw, C.B., C.M.G., M.S.

DISCUSSION ON OPERATIVE TREATMENT OF DIS¬
LOCATED HIPS, CONGENITAL AND PATHOLOGICAL.

Mr. H. A. T. Fairbank.

(I) Congenital Dislocation.

Open operations performed on congenital dislocations of the hip-joint are
of three types, each with its own particular purpose. The objects of these
operations are respectively :—

(1) To effect reduction.

(2) To prevent relapse in a hip already reduced (i.e., making an upper lip
to the acetabulum).

(3) To relieve pain in an old unreduced dislocation.

(1) Open Reduction.

All surgeons have now discarded such operations as the Hoffa- Lorenz [1]
—in which the acetabulum was deepened by a gouge, and if necessary the head
of the femur was pared to fit it—and Lane's [2] operation, in which no
attempt was made to get the femur into its proper position, but a new aceta¬
bulum was gouged out for it beneath the anterior inferior iliac spine. I have
only once performed this latter operation. Ludloff [3] opened the joint on
the inner side through an incision along the adductor magnus, reduction being
effected by the aid of a hook pulling on the neck of the femur; this method
of approach has obvious disadvantages. Burghard [4] in 1901 and again in
1903 published important papers on this subject, and gave sound directions for
reduction by the open method without doing unnecessary damage to soft parts
and without, of course, removing any cartilage or bone. He insisted on the
necessity for dividing the psoas as part of the procedure. He also excised an
elliptical portion of the capsule and closed the hole by sutures. Sherman [5]
operates through an anterior incision and, later, in those cases with much
anteversion, does a subtrochanteric osteotomy with rotation of the lower
fragment, the upper fragment being held by a nail driven into the bone and
retained there for six weeks. Bradford [6] has suggested the use of a shoe¬
horn as a means of directing the head of the femur down to the acetabulum ;
in some cases he has passed catgut through the neck of the femur and the
capsule close to the acetabulum, in an attempt to hold the head in position.
Galloway [7] is so disappointed with the results following manipulative treat¬
ment that he advocates wholesale open ‘operation even in young children,

[December 5, 1922.

16 Fairbank: Operative Treatment of Dislocated Hips

using a posterior incision and a blunted carpenter’s gouge in place of a shoe¬
horn. He also thinks there is no necessity for fixing an age limit for cases
suitable for operation. I entirely disagree with him in making no attempt to
select cases suitable for open operation. Manipulative reduction is un¬
doubtedly the method of choice at the present time, and in my opinion will
always remain so.

Indications .—The cases suitable for open reduction are in my opinion
those of from 3 to 6 years of age which have resisted two attempts at
manipulative-reduction. In unilateral cases over 6 years of age greater care
is necessary in selection, while no bilateral cases over 6 years should be
operated upon. Manipulations and stretching of muscles sufficient to allow
the leg to be put in the Lorenz position should invariably precede operation,
which should be performed some three weeks after such manipulation, the leg
being maintained in the Lorenz position during the interval.

Operation .—The child is tilted slightly to the opposite side by a sandbag
under the sacrum, and the full abduction position reduced somewhat, to
facilitate correct placing of the incision. The usual anterior incision is made
between the tensor fasciae femoris and sartorius, the upper end being continued
along the anterior half of the iliac crest, as Smith-Petersen [8] advises. A
broad sharp osteotome is a convenient instrument for cutting the muscles
from the periosteum, as it is sharp enough for this purpose and damages the
periosteum less than a knife. The front of the joint is cleared and the psoas
partially or completely divided near the lesser trochanter by means of a hernia
knife or probe-pointed bistoury. The joint is opened on the anterior aspect in
a line with and rather low on the neck. The capsule bounding the lower
margin of the isthmus is notched with a hernia knife, and the isthmus dilated
by opening a pair of scissors or other double-bladed instrument. Reduction is
then attempted by the usual manipulation, aided if necessary by a spoon¬
shaped lever, as little damage as possible being done to the cartilage of the
bones forming the joint. The incision in the capsule is closed carefully. The
thickness of the capsule varies enormously and is by no means always
increased. If the child is fit enough to stand prolongation of the operation,
an upper lip to the acetabulum is fashioned as described below. The muscles
are sutured back into place and the wound closed in the usual way. The leg
is fixed in plaster of Paris either in the Lorenz position, if fairly stable, or in
a further degree of abduction, the so-called “ axillary position.” The plaster
cast does not include the knee as a routine. The cast is cut off in a fortnight
for the removal of stitches and a fresh cast applied.

The usual after-treatment consists in retaining the leg in at least right
angle abduction for six months and applying further casts with slightly
diminished abduction for another two to four months. Walking is permitted
after the first six weeks unless extreme abduction has become necessary,
in which case the leg is brought to a right angle after three months and
retained in this position for another three months or more, walking being
permitted during this period. The later treatment is precisely the same as
that employed after manipulative reduction. In difficult cases the operation
is a severe one, and precautions to avoid shock should always be taken.

Anatomical Points .—At operation certain anatomical points have been
noted. The “ isthmus ” is usually definite and its dilatation a necessary
part of the operation ; in some cases, however, attempts at reduction have
completely failed in spite of free opening of the isthmus; in these it seemed
that every muscle passing in a vertical direction from pelvis to femur was

Section of Orthopaedics

resisting descent of the latter bone, and that nothing short of free division
of these muscles would enable reduction to be accomplished. Such free
division as appeared to be necessary did not seem to be justifiable, as, after all,
the stability of the joint, immediate and remote, must depend to a large extent
on the condition of the muscles around. The ligamentum teres is present in
some and absent in others, but is of no importance whatever. The gluteus
minimus is closely applied to the portion of capsule surrounding the displaced
femoral head and may he distinctly tendinous; it probably plays a part in
preventing further migration of the femur. The reflected head of the rectus
was in one case found arising from the capsule and had no direct attachment
to the bone, its direction being parallel to the surface of the ilium. In another
case a tendon was found crossing the inside of the joint in front of the
ligamentum teres : this was apparently the obturator externus. In yet another
a well-marked ridge-like fold of synovial membrane and capsule was seen
passing up from the region of the lesser trochanter to the lower margin of
the head, along the under surface of the neck.

Lastly, I would call attention to a condition seen in a bilateral case with
considerable displacement of both femoral heads. This condition does not seem
to have been described previously. It consisted of a more or less horizontal
ridge lying just above and behind the acetabular margin, with which it formed
a “ V,” open backwards. At first it was mistaken for the acetabular margin
till it was found to be soft and the acetabular margin was seen at a
slightly lower level. It is formed by a fold of synovial membrane and capsule
which wrinkle as the head of the femur descends towards the acetabulum.
The fold disappears when the head of the femur is forced upwards and the
capsule stretched, as would be the case when the child is standing. As
reduction is attempted this fold rises in front of the descending head, and
is pushed by the latter over the upper part of the rounded acetabular margin ;
in this way it undoubtedly acts as an obstruction to reduction in these difficult
cases with great shortening. Presumably this condition cannot be present
unless the femoral head is displaced well beyond the acetabular margin, and
the dilated capsule is applied to the dorsum ilii over a considerable area.
The patient in the case in which this condition was first noted took the
anaesthetic very badly and unfortunately died before completion of the operation.
At the post-mortem examination one was able to verify the impression gained
during the operation, and also to investigate a precisely similar condition
which was present in,the opposite hip. It is difficult to see how this tendency
to heaping up of the synovial membrane in front of the head of the femur
during attempted reduction can be avoided, as it only occurs, as we have
already stated, in those with much shortening, that is, just those cases in
which it would be impossible to get the head into the joint except over its
upper and back margin.

(2) Operation for making an Upper Lip to the Acetabulum .

Jackson Clarke [9] published a method in which he freed the cotyloid
ligament from the upper margin of the acetabulum from within the joint and
then inserted sutures to pull the ligament outwards. Albee [10] turns down
an osteo-periosteal flap at the upper acetabular margin, and holds it down with
bone wedges cut from the tibia, each graft being fixed by a bone peg. He uses
an external angular incision, turning the trochanter up with the attached
muscles.

When, in 1912, I began operating on the cases with a view to making an

18 Fairbank: Operative Treatment of Dislocated Hips

upper lip to the acetabulum, a periosteal flap was turned down somewhat
roughly so as to include minute fragments of bone, and this flap was held
in place over the capsule by stitches, no separate bone-graft being used. Only
one (fig. 1) of these early pre-war cases operated upon ten years ago can be
traced, and this case is shown to-day. The result is excellent radiographically,
and apparently functionally, but the function is difficult to estimate since the
other hip, treated by manipulation only, has relapsed. This case was reported
last year at a meeting of the British Orthopaedic Association [ 11 ]. In recent
cases a bone-graft cut from the ilium has been made use of, in addition.

Fig. 1.—Girl. Bilateral congenital dislocation. Aged 5$ at time of open operation
on right hip ; periosteal dap turned down above acetabulum. Bone-graft not used.
Radiogram shows result nine and a half years later.

Indications .— (a) When relapse has followed manipulative reduction and
the patient is still 6 years old or younger, i.e., young enough for fair prognosis.
Most careful selection of casos over 6 years suitable for operation is necessary.
( b) Patients of 3 to G years old (perhaps older) with marginal displacement
only, should be operated upon forthwith, i.e., three weeks after manipulative
reduction. In these cases the upper acetabular margin is flattened by the
pressure of the femoral head, which lies in contact with it, and as a result
the lip is more feebly developed than in those with a greater amount of

Secticm of Orthopaedics

displacement of the head. Reduction by manipulation in such a case is easy,
but the joint is found to be extremely unstable : relapse is certain to occur
if nothing further is done, (c) This operation should be coupled with that of
open reduction whenever possible. Manipulative reduction, when possible,
is invariably performed three weeks previously and the Lorenz position
maintained until the patient is on the operating table again.

Operation .—The joint is exposed as in the operation described above, but
the capsule is not opened. A curved incision is made in the periosteum
parallel to and half an inch above the upper margin of the acetabulum,
curving down more behind than in front. The periosteal flap thus marked out
is turned down together with a flake of bone. This flake is necessarily in
fragments, but each of these is attached to the periosteum. It is difficult
to place the osteotome in the correct plane for cutting an ideal bone-flap.
The separation is carried down to and just beyond the acetabular margin.
Care is taken to avoid breaking through the articular cartilage into the joint.
Since the margin of the socket is ill defined and rounded, it is not easy to
hinge the flap at exactly the right spot. The tendency in my hands has been
in the direction of making the artificial lip too high. The reflected head of the
rectus is left attached to the flap and turned down with it. Three thread
stitches are inserted through the margin of the osteo-periosteal flap and the
capsule, the former being held well out over the latter. A bone-graft, either
crescentic or shaped like a small segment of a circle, is cut from the dorsum ilii
a little below the crest: it includes the periosteum, outer compact layer of bone
and some of the cancellous tissue beneath. If the whole thickness of the ilium
is included at the lower part of the graft no harm results. This graft is laid on
top of the osteo-periosteal bone-flap, medulla to medulla, its straight edge
being well pushed into the angle of the bony cleft formed when the flap is
turned down. The graft is easily bent to fit. The graft is held in contact
with the flap by a small bone peg also cut from the ilium, or by a stitch or two,
or both. The muscles are stitched back into place and the wound closed.
Plaster is applied with the leg in rather more than 90° abduction. The wound
is dressed in a fortnight, a fresh cast applied, and the treatment carried on as
outlined above.

It should be noted that the joint is not opened unless open reduction forms
apart of the operation, and also that the periosteal flap and bone-graft are not
intended to forcibly retain the head of the femur in place at once, as in the
operation Mr. Trethowan performs. Reduction is maintained by the position
of the limb, the flap and bone-graft simply acting as the foundation for the
growth of an exaggerated upper lip to the acetabulum.

The reason why this operation should not, in my opinion, be regarded as
the routine procedure in the older cases is that the additional risk of such an
operation is hardly justified when it is remembered that absorptive and
other changes are frequent sequelae of reduction by all methods in older
children. Of the two operations the second would seem to be more fre¬
quently justifiable in children over 6 years than the first or open
reduction.

Note .—Although 3 to 6 years are mentioned in the indications for both the
above operations, I have only once operated by the open method in patients
under 4 years of age. Occasionally some special difficulty is met with,
usually in a bilateral case, which may call for open operation even at this
early age.

20 Fairbank: Operative Treatment (/Dislocated Hips

Results of these Operations .

Of eleven hips in which open reduction was attempted only three remain
reduced. Two showed good X-ray and functional results two and a half and
four and a half years after reduction : they were then lost sight of. The
third developed arthritis and became ankylosed, but later became slightly
mobile again. A fourth developed anterior displacement of the head of the
femur as a late result, and then passed into the hands of another surgeon,
who, I believe, eventually got a fair result. Another resulted in “ anterior
reposition” with good function. Not much to offer in the way of results!

The acetabular lip-forming operation has been performed on eleven hips.
One, without a separate bone-graft being used, has been shown to-day with a
satisfactory result. Three others are satisfactory so far and promise well.

Fig. 2.—Girl aped 4£. Congenital dislocation of left hip. Radiogram taken
seventeen months after operation for making upper lip to acetabulum, bone-graft
being used. Note well formed upper lip of left acetabulum. The right hip now looks
somewhat unstable.

(Two of these have been shown at the meeting, figs. 2, 3, 4.) ^ Four have
resulted in “ anterior repositions,” one showing marked signs of “ absorptive
arthritis.” One relapsed, while the result in the others is unknown. Again, the
results are not brilliant, but they are in some respects encouraging. To judge
from the late radiographic appearances in some, nothing might have been done
to fashion an upper lip, yet in a few' the upper lip is redundant. In spite
of failures, I think the lines to work upon are those which aim at improving
the placing and fixation of the flap and graft, at the same time avoiding
traumatism of the articular structures to the greatest possible extent.

Section of Orthopaedics

Fig. 3.—Girl aged 5$. Congenital dislocation left hip. Radiogram, with hip in
plaster one week after operation for making npper lip; oone-graft from ilium fixed
over osteo-periosteal flap.

Fig. 4.—Same as fig. 3. Nine months after operation, showing head of femur in place
and good upper lip to the acetabulum.

22 Fairbank: Operative Treatment of Dislocated Hips

(3) Operation for the Relief of Pain .

The pain from which the untreated or imperfectly cured case sooner or
later suffers is, in my opinion, undoubtedly due to arthritis, and not to
stretching of the capsule. There is no evidence of increase of deformity with
the onset of pain. We cannot discuss to-day all the operations which might
be performed in these cases. I think the pain must be severe before an opera¬
tion becomes justifiable. I am inclined to think that simple excision of the
head of the femur through an anterior incision is the best method to adopt.
Retention of the leg in abduction for two or three months is followed by the
use of a calliper splint for at least a year. It is possible that detaching the
trochanter and fixing it at a lower level, as suggested independently by
Whitman [12] and by Platt [13] when .operating for other hip conditions,
might improve the functional result. I have here two specimens of femoral
heads removed during the last year.

Case I —that of a girl, aged 13, with a congenital dislocation which had never
been treated. She complained of pain and stiffness and increasing limp for the past
two years. X-rays showed a fairly well-shaped head in a shallow false acetabulum at
the site of the upper acetabular margin, but no changes to suggest the presence of
well-marked arthritis. During the months the child was under observation the
symptoms were undoubtedly getting worse ; she could not walk a mile. After tenotomy
of the adductors and abduction of the leg one month previously, the head of the femur
was excised through an anterior incision. Capsule very thick, one-third of an inch at
least; synovial membrane thick, and in a condition of marked villous arthritis; head
of femur slightly flattened over a curved area on the inner and upper aspects; cartilage
was pitted in places; ligamentum teres absent; false acetabulum remarkably smooth
and apparently covered by good articular cartilage ; capsular isthmus well marked ; an
instrument passed through it made out the true acetabulum to be small and apparently
full of villous growth.

Case II. —Patient, a girl, aged 17, had her unilateral congenital dislocation reduced
by me at the.age of 2^. Four and a half years later the function was perfect, and the
joint considered satisfactory. Four years ago, that is ten years after reduction, she
began to complain of pain after an attack of appendicitis ; the mother states that a
diagnosis of tubercle was made and a splint ordered. When seen eighteen months ago
the hip was almost fixed in an adducted position. X-rays showed the head of the femur
resting opposite the upper lip of the acetabulum, i.e., in a position of “ anterior reposi¬
tion/’ with marked alteration in the outline of the bone. The pain had then disappeared,
but re-appeared later and gradually got worse. At operation the capsule was not more
than one-eighth of an inch thick, and was closely applied to an irregularly shaped femoral
head; synovial membrane almost everywhere unrecognizable; ligamentum teres very
thick and strong ; practically no cartilage left on head of femur, which shows deep
groove across the top in an antero-posterior direction, and considerable new bone
formation around the neck. False acetabulum small compared with head of femur,
but well covered with fibro-cartilage ; entrance to old acetabulum could not be found.

Both the above patients are now walking in callipers, and are free from pain.

Dr. Reich, of Cleveland, and other surgeons who have recently visited Vienna,
have spoken to me with enthusiasm of an operation devised by Lorenz, modified
by his assistant, Hass, and performed by both of them, for such cases as those
just mentioned. As it may be new to those present, as it was to me, a brief
reference may be of interest. The operation consists in an oblique sub¬
trochanteric osteotomy, the line of section passing upwards and forwards rather
than upwards and inwards. The wound is closed, the thigh abducted, and by

Section of Orthopeedics

manual pressure the upper end of the shaft, and with it the bone immediately
above the section, is pushed in towards the acetabulum. After three months in
a plaster cast at 45° abduction the patients walk without apparatus of any
kind. The results are said to be surprisingly good. For an ununited fracture
of the neck of the femur, the head of course being in the joint, the procedure
is slightly modified, the section of the bone being then made obliquely upwards
and inwards.

(II) Paralytic Dislocations.

Careful selection of cases suitable for operation is necessary, as in many
the extent and severity of the paralysis contra-indicate any attempt being made
to stabilize the hip. In the last three years I have had four cases, and only con¬
sidered one suitable for operation. Reduction is, of course, easy; moderate
abduction is sufficient to prevent the femur from slipping up.

The operation performed was much the same as that for making an upper
lip to the acetabulum in congenital dislocations, but wedges of bones were
inserted to hold the flap and graft down, as in Albee’s operation. In this case
the mistake was made of making the lip too high, as can be seen in the skiagram.
After such an operation the leg is fixed in plaster of Paris in moderate abduction
and slight internal rotation.

(Ill) Dislocation following Arthritis.

No attempt has been made to effect reduction by operative measures in old-
standing cases. In early cases reduction can easily be accomplished by simple
abduction under an anaesthetic, and no operation is necessary. In an old-standing
case a modified arthroplasty was attempted, with poor result. As a rule one has
been content with obtaining abduction by tenotomy of the adductors and
gradual correction of deformity or by an osteotomy. In one or two I have
exsected a portion of the obturator nerve with the idea of diminishing the
tendency to adduction. I regret that I have not not been able to bring
before you any brilliant and new operative methods, but I hope these few
remarks may serve their purpose, namely, to act as a foundation for
discussion.

REFERENCES.

[1] Lorenz, A., Central, f. Chir., 1892, xix, p. 633. [21 Sir Arbuthnot Lane, Trane. Clin.

Soc., 1893, xxvi. [3] Ludloff, Quoted by Sir R. Jones and D. M. Aitken in Latham and English,
“ System of Treatment,” i, p. 949. [4] Burghard, Brit. Med. Joum., 1901, ii, p. 1156; 1903, ii,

p. 457. [5] Sherman, Surg. Gyn. and Obst ., 1914, xviii, p. 62. [6] Bradford, Amer. Joum .

Orth. Surg., 1909-10, vii, p. 57. [7] Galloway, Joum. Orth. Surg., 1920, ii, p. 390.

T6] Smith-Petersen, Amer. Joum. Orth. Surg., 1917, xv, p. 692. [9] Jackson Clarke,

Lancet , 1909, ii, p. 925. [10] Albek, “Bone-graft Surgery,” 1917, p. 245. [11] Fairbank, Brit.

Joum. Surg., 1922, x, p. 24. [12] Whitman, Surg. Gyn. and Obst., 1921, p. 478. [13] Platt,

Brit. Med. Joum., 1922, i, p. 672.

24 Discussion on Operative Treatment of Dislocated Hips

Mr. R. C. Elmslie

said he had had little personal experience of the open operation for congenital
dislocation and in cases which had come under his observation the results
were disappointing. In two children he had formed an upper lip to the
acetabulum by bone-graft, but in both the dislocation recurred. He congratu¬
lated Mr. Fairbank on the excellent result which had been obtained in the
patients shown to illustrate this operation. The effect of reduction might
be highly satisfactory for some years and yet the ultimate result might be
unsatisfactory. He had recently seen a woman whose age was in the late
twenties and whose dislocation was reduced by Kocher in 1902; the hip had
remained stable for twenty years but she was now developing arthritis.
He remarked on the fact that Mr. Fairbank had omitted to mention arthrodesis,
which he thought might be tried more often where there was marked deformity
or pain.

Mr. W. H. Trethowan

agreed with Mr. Elmslie that the results of open reduction were a little
disappointing. He did not usually sew up the capsule, which might account
for some relapses. It was hazardous in these cases to maintain the limb in
the Lorenz position for long owing to the tendency to contracture, and
in avoiding this the limb had sometimes been brought down prematurely.
As to the grafted-lip operation there were two difficulties to combat, viz., the
anteversion of the head and neck and the bad acetabulum ; relapse was as
much due to the one as to the other. It was difficult to get the grafting done
if the limb was already in the Lorenz position. For this reason he opened the
joint freely, levered the head into position with the spoon and used a stout
graft, taken from the front of the iliac crest and fixed with ivory pegs, to hold
it in this position. In a boy, 10 years old, he had reduced the dislocation
completely, inverted the limb for six months and afterwards corrected the
position by osteotomy. He regarded fixation of the hip-joint as a serious
disability and for this reason would not advocate arthrodesis. He regarded
Mr. Fairbanks results as stimulating.

Mr. D. M. Aitken

had done excision in dislocation following paralysis and old sepsis. He did not
think that in children from 3 to 4 years of age it ought ever to be impossible
to reduce by manipulation. Many adults got about well without pain ; others
had pain from lordosis. He had seen a patient of Sir Robert Jones in whom
trans-trochanteric osteotomy of both femora had been done and the limbs
arranged to correct the lordosis, with excellent result. He would like to know
the mortality of the open operations.

Section of Orthopaedics

Mr. A. B. Bankart

said that if the femur was fully reduced and kept in position until there was
evidence of stability there was no likelihood of relapse. Some cases were
quite irreducible. In older patients the joint got stiff after reduction, first
from spasm and then from arthritis. Reduction by the open method was
more likely to be followed by stiffness. In the cases in which he had done
the open operation he had used a posterior incision, and treated the joint as if
no open operation had been performed. The Lorenz position was not a normal
attitude for the hip and he thought the limb should be turned in as early as
possible. With regard to one of Mr. Fairbanks cases he suggested that the
femur was not being kept down by the graft but by new bone which would
have been thrown out under any circumstances.

Mr. R. A. Ramsay

also commented on the Lorenz operation and position, and showed two children
in whom reduction of the dislocation by manipulation had been followed by
pseudo-coxalgic changes in the femoral head and m irked stiffness. A weight-
extension applied for six months had resulted in free movement, but the changes
in the head remained.

Mr. T. P. Noble

showed a patient too old for reduction in whom he had done a sub-trochanteric
osteotomy, and placed the limbs in wide abduction and hyperextension. He
had done excision for pain in the back.

Mr. H. A. T. Fairbank (in reply)

said that the results of open reduction were not good ; he had done ten before
the war but only one since. Mr. Trethowan’s method of lip-grafting would
probably have been useful in cases in which he had abandoned open operation
owing to the joint being very unstable. He thought it probable that difficulty
in bringing down the limb after operation was due to arthritic changes, and not
to matting of the surrounding structures. With regard to mortality, one child
had died, but death was probably largely due to the anaesthetic. He had con¬
sidered arthrodesis, but unless the patient had violent pain he would leave her
alone ; he would prefer excision to arthrodesis. It was highly important that
the profession should realize that these patients should come under treatment
at the earliest possible age, not when 5 or 6 years old, as was so often the case.
Personally he had not always been able to reduce double dislocations in children
at the age of 4, once even he had been unable to do this at the age of 3. If the
Lorenz operation failed and relapse occurred he would do the lip-grafting opera¬
tion. He did not agree with Mr. Bankart that new bone was always thrown out
after reduction, forming a roof to the acetabulum; he had seen some cases
in which this did not occur. Pseudo-coxalgic changes did not interfere with
cure, but the mushroom head remained.

Davis: Multiple Exostoses

Case of Multiple Exostoses.

By Acton Davis, F.R.C.S.

PATIENT, a boy, aged 11, with upper two-thirds of left humerus involved
by tumour, 26 in. in girth and 7 in. in length ; noticed at age of 3 ; girth in¬
creasing by 1 in. yearly. Other swellings affected both ends of femora, lower
end of right radius, both scapulas, both ends of tibiae, and lower end of left
fibula. Two brothers, two uncles, one aunt and grandfather have exostoses.

The parents would not allow amputation, and he was considering removal
of upper end of the humerus with insertion of graft later.

Mr. R. C. Elmslie said he would be loth to amputate, and would make incisions,
leaving a wide strip of skin and lifting the soft parts. The main difficulties would be the
musculo-spiral nerve and hamorrhage near the shoulder-joint.

Section of ©rtbopatfrtcs.

President—Mr. T. H. Openshaw, C.B., C.M.G., M.S.

Case of Haemophilic Arthritis of the Knee.

By R. C. Elmslie, F.R.C.S.

Patient, a boy, aged 9, one of a family of bleeders, this fact being
shown in the accompanying diagram. Symptoms of haemophilia commenced
at the age of 2, with bleeding from the gums, the right ankle-joint became
affected at the age of 5 and the left knee-joint at the age of 6. The
patient has several times been into St. Bartholomew’s for treatment.

At the age of 5, injections of horse serum and transfusion of the mother’s
blood was tried. At the age of 6, these were repeated on two occasions

*P*tien£&

Patient

G Patients drot/rer*
f CoagP t/mr norm*/)

^ Hae/nophtZtc.

without altering the coagulation time of the blood, which was 4*6 times
the normal. He was then treated by intradermal injections of horse serum,
and the coagulation time fell to normal. Following these treatments he was
free from attacks of bleeding for nearly two years.

An acute effusion into the knee-joint occurred one week ago, and the boy is
at the present time being rested on account of this.

The treatment of this patient by intradermal injections was described by
H. W. C. Vines, in the Quarterly Journal of Medicine , April, 1S20, p. 259,
“ Anaphylaxis in Treatment of Haemophilia.”

My—Or 1

[February 6, 1923.

Elmslie : Arthritis; Both: Kohler's Disease

Case of Arthritis due to Dental Sepsis diagnosed and treated

as Tuberculous.

By R. C. Elmslie, F.R.C.S.

Patient, aged 20.

November, 1920 : Pain and swelling of the right knee : temperature raised
in the evenings. Went to Whitstable, where she was treated for tubercle
with plaster and splint.

July, 1922: Returned to work, with knee on plaster splint.

October, 1922 : Recurrence of pain. Went to St. Bartholomew’s Hospital.
Knee then stiff and swollen; forced extension painful; flexion movement
absent. Teeth X-rayed; four extracted ; streptococcus isolated from the
roots and vaccine given. No local treatment since October.

Knee has improved very greatly, and is now very little swollen ; move¬
ment free from full extension to right angle.

Two Cases of Kohlers Disease.

By Paul Bernard Roth, F.R.C.S.

Case I .—A boy, aged 5, first seen on January 18, 1923, was said to have
fallen and hurt his left foot at Christmas; he had since walked with a limp,
and his foot was noticed to be swollen. Family history revealed nothing

Fig. 1.—Radiogram of Case I, antero-posterior view.

abnormal. Examination was negative, except that there was considerable
tenderness to pressure over the scaphoid bone. Radiograms of both feet by
Dr. Bracken showed that whereas the right scaphoid bone was normal, the
left ( see figs. 1, 2) was distinctly diminished in size and extremely dense.

Section of Orthopaedics

•29

Case II .—A boy, aged 7, first seen on November 3, 1922, had been sent
by Dr. Cathcart Irwin as a case of left Kohler’s disease, with the history
that the trouble had begun last June, had abated, had recurred again in
August, had again abated, and had then relapsed, for the second time,
recently. Family history: Seven of mother’s near relatives tuberculous;
patient’s brother, aged 13, had a tuberculous eye, and his sister had died of
tuberculous peritonitis when months old. On examination : Tenderness to
deep pressure over the scaphoid of left foot. Radiograms showed that both
feet were affected, the scaphoid bones being small and dense, the appearance
suggesting that they were only partly formed.

Fig. 2.—Radiogram of Case I, lateral view. •

Unusual Form of Syndactyly.

By H. A. T. Fairbank, D.S.O., F.K.C.S.

R. M., BOY, aged 16 months, a twin ; the other, a boy, being normal. No
history' of congenital deformity in family.

Right hand : First, second and third fingers fused at terminal segments, the
proximal portions being separate. The terminal segments show contraction
rings so that the whole deformity looks as though it had resulted from a string
tied round near the tips of the three fingers. Left hand: Normal. Right foot:
Congenital contraction rings of second and third toes. Left foot : Congenital

Fairbank—Aitken —Heath—Gripper

talipes equino-varus now well on the way to cure. Partial webbing of second
and third toes. X-ray; Right hand shows terminal phalanges of united fingers
unfused.

Traumatic Osteo-arthritis of Neck treated by Bone-graft.

By D. M. Aitken, F.R.C.S.

PATIENT, J. E. G., was blown up in a mine in France on July 26, 1916.
A month later he fell and again hurt his neck. In 1917 he was discharged
from the Army as suffering from spinal caries. In December, 1921, he was
admitted to the hospital at Shepherd’s Bush obviously in pain and supporting
his chin on his hands like a case of acute cervical caries. Skiagram showed
crush fracture between fifth and sixth cervical vertebra and osteitic changes in
several vertebra. Kept at rest with plaster collars for nine months, but the
slightest movement caused pain. Bone-graft was inserted from second cervical
to first dorsal spine in October, 1922. Patient has been free from pain since
the operation.

Late Result of Beef-bone Graft of Humerus.

By Maynard Heath, M.S.

This boy was shown at the meeting of this Section on November 1,
1921. 1 The upper end of the humerus had been resected for fibrocystic
disease and replaced by a beef-bone graft inserted subperiosteally. The
function of the arm is very good though abduction is slightly limited owing
to angulation of the shaft of the humerus. X-rays show that the graft has
been completely absorbed and replaced by bone which closely restores the
original contour of the humerus..

A Case of Congenital Subluxation of Humeri.

By Walter Gripper, M.B.

This girl, well grown and aged 9, is an inmate of an orphanage. The con¬
dition first came under observation owing to the nurse, when applying a
vaccination dressing, noticing that if either arm was raised higher than the
shoulder a distinct jerk in the joint could be felt as the head of the bone
slipped in and out of place. The child feels no pain and there is apparently no
disability at present. There is no history of injury or strain. The skiagrams
of both shoulders show a similar appearance. The glenoid cavity is appar¬
ently defective, its surface forming almost a straight line with the axillary
border of the scapula, and with the arm raised there is a considerable interval
between the glenoid fossa and the head of the humerus.

1 Proceedings, 1922, xv (Sect. Sur^., Sub-sect. Orth.), p. 7.

Section of Orthopaedics

Two Cases of Fractured Neck of Femur in Training-ship

Boys.

By W. T. Gordon Pugh, M.D., B.S.

Case I. —F. F., aged 15, fractured the neck of his left femur on March 15,
1922, by falling on the hip a distance of 4 or 5 ft. over banisters. On the next
day he was able to walk, but with some pain. Subsequently he remained in
bed until admission to hospital three weeks later. On admission he lay with
the left limb abducted and the great trochanter prominent; there was shorten¬
ing of half an inch. Flexion movement was limited to about 90° ; abduction,
internal rotation and extension were limited; external rotation was increased.
Movements were rather painful, but could be carried out without much spasm.

32 Pugh: Two Gases of Fractured Neck of Femur

There was local tenderness over femoral neck. X-rays showed a fracture of
the neck of femur at its middle, with slight upward displacement of the lower
fragment producing some degree of coxa vara. The position was improved by
abduction under an anaesthetic, and when examined on October 5 the shorten¬
ing was less than, half an inch and movements in all directions were normal.
The walking Thomas splint was omitted in December.

Case 11. —A. F., aged 15, also sustained a fracture of the neck of the left
femur. On June 28, 1922, he was jumping over a rope at drill and slipped in
alighting, with the result that his thighs were widely opened and he fell astride
on the deck. There was not much pain, but he could not stand on the left leg.
He was admitted to hospital on the same day. The limb was in a position of
extreme external rotation (90°); the trochanter was li in. higher than on the
uninjured side. A skiagram showed a fracture at the junction of the neck with
the great trochanter, the neck lying at right angles to the line of the shaft.

The position was corrected under an anaesthetic; he was treated on an
abduction frame and not permitted to use the limb for six months. About a
month after getting up he complained of slight pain in the joint, and a skiagram
showed some absorption of the upper part of the head of the bone. The
shortening is about one-third of an inch and movement at the joint is free.
On account of the recent pain he has now been supplied with a calliper.

Section of ©rtbopfefcics.

President—Mr. T. H. Openshaw, C.B., C.M.G., M.S.

DISCUSSION ON THE OPERATIVE TREATMENT
OF SPASTIC PARALYSIS.

Mr. A. S. Blundell Bankart.

SPASTIC paralysis is due in the great majority of cases to a permanent
defect of the upper motor neurons. It is, therefore, essentially an incurable
condition, and the most that can be expected from surgical treatment is relief
from some of its most obvious mechanical or functional disabilities.

The cases with which we have to deal are chiefly, though not exclusively,
the cerebral palsies of children—diplegias, hemiplegias, paraplegias, and less
often monoplegias. These children, in consequence of their spastic condition,
suffer from certain contractures of the limbs, and it is to the relief of these
contractures that surgical treatment is almost entirely directed.

The typical contractures of the lower extremity are plantar-flexion of the
foot (spastic equinus), flexion of the knee, and adduction of the thigh ; while
in the upper extremity pronation of the forearm and flexion of the wrist are
most characteristic.

We cannot, however, afford to ignore other features of cerebral paralysis,
for it is upon these far more than upon the contractures that the ultimate
prognosis depends.

In a large proportion of the cases there is some degree of mental deficiency.
It need hardly be said that we do not operate on idiots. But mental impair¬
ment of less degree is no contra-indication to treatment, since the state of the
child may be materially improved thereby.

Spastic paralysis, as its name indicates, is not merely spasticity, but also
paralysis. In other words, there is loss of motor power distinct from that
which results from the rigidity of the limbs. The amount of motor weakness
varies in different cases, and when it is pronounced it is a serious factor in
the prognosis.

Involuntary movements—athetosis, variable spasm, and associated move¬
ments, when well marked, are a contra-indication to the ordinary methods of
treating spastic contracture. Their treatment constitutes a separate problem
which has not yet emerged from the experimental stage. Lastly, progressive
disease is a definite contra-indication to surgical treatment.

J V—Or l

[March 6 , 1923 .

34 Bankart: Operative Treatment of Spastic Paralysis

Physiologically, spastic contracture is a tonic reflex contraction of the
muscles—a spinal reflex released from the normal inhibitory control of the
higher centres of the central nervous system. It disappears during deep
anaesthesia and when the reflex arc is interrupted in any part of its course.

It is remarkable how long this physiological contracture may persist with¬
out any permanent change in the structure of the muscle. It may persist in
this state for years. But eventually an anatomical or structural shortening
is added to the physiological contracture, and the deformity becomes fixed.
When structural shortening exists, it must be treated by direct attack upon
the shortened muscle, by stretching it, or by dividing or lengthening its
tendon. But when we are dealing with pure physiological contracture, we
have a choice of methods. We may attack it either on the afferent or on the
efferent side of the reflex arc.

Non-operative treatment is useless. Most of these cases have been treated
for months or even years by massage and manipulations and sometimes
electricity before the patients come to us, and I have never yet seen any
permanent benefit result from such treatment.

The attack on the afferent side of the reflex is known as Foerster’s opera¬
tion, and I will deal with that next, although it does not come next in chrono¬
logical order. In 1908 Foerster suggested that as spasticity was a spinal
reflex, its intensity might be diminished by cutting off a sufficient number of
the afferent impulses entering the spinal cord at the appropriate level. He,
therefore, advised, and many surgeons have since practised, division of certain
of the posterior nerve roots in cases of spastic paralysis.

This procedure is no doubt physiologically correct, but it is in advance of
our knowledge of localization in the posterior roots. For, whether you regard
spasticity as being equally distributed in a limb, and the contractures as due
to the preponderating action of the more powerful muscles, or whether you
consider that some muscles are more spastic than others, in either case the
contracture disabilities are local, and you cannot localize the effects of posterior
root section to particular groups of muscles. So that, in spite of the most
elaborate directions worked out by Foerster and others for particular cases,
the results of this operation have been generally very disappointing, and I
believe I am right in saying that it has been abandoned or at any rate reserved
for exceptional cases by nearly every orthopaedic surgeon.

So we are left with the attack on the efferent side of the reflex, and I would
include on the efferent side both the nerve and the muscle. For I want to
emphasize the fact that whether you attack the nerve or the muscle, the
principle of the operation is the same—namely, to diminish the effective action
of the preponderating muscle or muscle group.

One can diminish the effective action of a muscle by destroying it, or part
of it, or by lengthening its tendon, so that its effective range of action is
diminished. The transplantation of a muscle to a place where it is not
wanted seems to me to be a needlessly elaborate and clumsy way of accom¬
plishing the same thing. The simplest way of destroying muscle is to cut out
its nerve supply. The simplest way of lengthening a tendon is to cut it
across and allow the resulting scar to organize in continuity with the tendon,
though in some cases a plastic operation is preferable.

)j Now, for many years orthopaedic surgeons have claimed that it is possible
to set almost any spastic child upon his feet, and to get him walking somehow,
provided only that he has sufficient intelligence to try to use his legs. This
result has been attained usually by a long course of treatment, the details of

Section of Orthopaedics

which are, of course, well known to you. Briefly, in a typical case of cerebral
diplegia, the adductors are divided, and the thighs widely separated, the ham¬
strings are divided, and the knees kept straight on splints, and the tendo
Acbillis is lengthened by a plastic operation.

Originally, the adductors were divided by simple tenotomy. But it was
found that the contracture returned so rapidly that many surgeons made an
open incision and excised portions of these muscles ; and for the same reason
portions of the hamstrings have been excised. Nevertheless, it was found that
the tendency to recurrence of the contractures was so great that it was
necessary to keep the limbs for a very considerable time in some form of
apparatus with the thighs fully abducted, and the knees extended.

But even then the patient’s troubles were not over, for in order to prevent
relapse many surgeons found it necessary to put these patients into walking
instruments for a long time after the correction of their deformities. How long
such instruments must be worn before all danger of relapse is over, I do not
know. But I have seen patients wearing them for years, and I have seen also
cases of relapse in patients who had been treated without instruments, or who
have discarded them too soon. Lastly, it must be admitted that the gait of
aspastic patient wearing double instruments to the pelvis, and with the knee-
joints locked in extension, is a very poor apology for normal progression.

• Now, instead of dividing or lengthening tendons, one can diminish the
effective action of muscles by lessening the number of fibres that take part in
their contraction. This, after all, is the most natural way of regulating the
strength of muscular contraction. For the strength of contraction in a given
muscle is not due to any variable property of the contracting fibres, but is
determined solely by the number of fibres brought into action by the stimulus.
So that, by destroying a sufficient number of muscle-fibres, we can diminish
the strength of contraction of a muscle or muscle-group to any extent we
please.

In spastic contracture we have a powerful group of muscles in a state of
tonic contraction so intense that it holds the part in a position of deformity,
and prevents movement in any other direction. By destroying a sufficient part
of this muscle-group, we abolish the excessive contraction, and get rid of the
contracture deformity, while leaving sufficient muscular power for all practical
purposes. The simplest way of destroying muscle fibres is to cut out their
nerve supply, and this is the principle of Stoffel’s operation for spastic
contracture.

I will not give details of these operations in different regions. It is enough
to say that for adductor contracture of the thigh one resects one or both
divisions of the obturator nerve, for flexion contracture of the knee one resects
the nerve tracts to the long head of the biceps, the semimembranosus, and part
or the whole of the semitendinosus ; while for the equinus contracture of the
foot one resects one-half or two-thirds, more or less, of the nerve tracts
to the gastrocnemius and soleus. In each case the relief of the contracture is
immediate and permanent, yet sufficient muscular power is retained to adduct
the thigh, flex the knee, or raise the heel from the ground when required.
Similarly, the pronation and flexion contracture of the upper extremity may be
relieved by destruction of a sufficient part of the nerve tracts to the pronators
a od flexors.

To Stoffel we owe the development of the “ cable theory ” of nerves. He
demonstrated that in the main nerve trunks of the limbs the various nerve
tracts maintain their identity and independence at lease for a considerable

36 Bankart: Operative Treatment of Spastic Paralysis

distance, and that the cross-section anatomy of a large nerve is fairly constant
in any given situation. So that, given a knowledge of the position of these
tracts, we can pick out and isolate from the main nerve trunk the nerve supply
of any required muscle-group, and we can then destroy as much or as little of
it as we please.

The ease with which any main nerve trunk can be exposed in a limb, and
the fine adjustment and variation that are possible in dealing with the nerve
tracts, impart to this operation both a simplicity and an adaptability that are,
I think, unattainable by any other method of operating.

As examples of variations from what one has come to regard as the typical
operations, I would instance cases in which there is severe flexor spasm of the
toes, making walking difficult and painful, others in which there is peroneal
spasm causing pronounced eversion of the foot, and yet others in which there
is persistent internal rotation of the thigh. In each case the contracture is
disposed of by resecting a sufficient part of the appropriate nerve tract—the
flexor tract to the toes on the deep surface of the internal popliteal nerve,
the peroneal tract in the middle of the external popliteal, and the tracts to the
internal rotators of the thigh in the superior gluteal nerve.

I need hardly remind you of the consequences of destroying the nerve
supply to a muscle. You know that the muscle immediately becomes
completely and permanently paralysed. Such a muscle is pale, flabby, and
atrophic. It has no tendency to shorten. On the contrary, it is very easily
stretched, and, when stretched, it remains elongated and relaxed.

And this is the outstanding feature of Stoffers operation as compared with
operations directly upon muscles or tendons—that the effect of the nerve
destruction is immediate and permanent; there is no tendency to recurrence
of contracture in the paralysed muscles ; there is, therefore, no need to keep
these patients in abduction frames or other apparatus ; they can be got up
immediately after the operation; and they require no walking instruments
afterwards. In a word, Stoffel's operation abolishes the prolonged mechanical
treatment and after-treatment of spastic paralysis, and in particular the use of
all forms of splints and apparatus.

With regard to the end-results, it must be remembered that spasticity is
but one of the disabilities of cerebral paralysis. Even after the removal
of their contractures, patients in the severer cases never walk quite naturally,
and they are apt to be awkward and ungainly. Yet, to take a child who
cannot even stand upright, and to put him on his feet and get him walking
somehow, is at least a result worth having, while in less severe cases there is
often a very striking improvement in stability and locomotion.

Fortunately, with the exception of idiots, every child instinctively tries
to use his legs, so that the only after-treatment required is practice and
encouragement, which in most cases can quite well be given at home.

In the case of the upper extremity the conditions are different. A patient
with one sound arm and one disabled one will use the sound arm for
everything that he can do with it, and there is hardly anything in the ordinary
daily routine of life that cannot be done quite well with one arm. So that in
hemiplegics, at least, there is no natural incentive to use the affected arm after
operation, and we depend much more upon the patient’s intelligence and
co-operation in order to obtain a useful result. Still, some of these patients
do show a very considerable improvement as regards function, and the
cosmetic result alone is sometimes worth having, for the characteristic
pronation-flexion contracture is an unsightly deformity, and the appearance
of the limb is often much improved by the relief of these contractures.

Section of Orthopaedics

In conclusion, I would submit:—

(1) That J3toffers operation is by far the best method of treatment which
has yet beerr devised for the relief of spastic contracture.

(2) The actual operation in each region is quite a minor operation and easy
of performance.

(3) It admits of a degree of precision and adjustment to the needs of
individual cases, such as cannot be obtained in any other way.

(4) Its results are immediate and permanent.

(5) The very nature of the resulting intentional paralysis makes recurrence
of the contracture impossible.

(6) Prolonged after-treatment and the use of splints or other apparatus are
entirely unnecessary.

The President (Mr. T. H. Openshaw)

remarked that he had always operated on spastic paraplegic cases by division
of tendons and muscles. He considered lengthening of the tendo Achillis by
subcutaneous tenotomy invariably successful, but the danger lay in over¬
correction. It was necessary to remove a large portion of the hamstrings at
the knees in order to avoid rapid reunion and relapse : simple division by the
open method was not sufficient. A large portion of the adductor longus should
be removed, and the adductor brevis and gracilis freely divided by open opera¬
tion. In severe cases in which the flexion of the knee and hip had been
allowed to persist for many years, lengthening of the adductors and hamstrings
would not be a sufficient enough measure to enable the patient to walk upright.
In such cases it would be found that the psoas muscle was contracted and it
must be divided. He had repeatedly divided this muscle at its insertion to the
small trochanter through a posterior vertical incision at the lower border of the
gluteus maximus muscle. He had performed Foerster’s operation in two
cases, but the operation was exceedingly difficult and severe, and the result was
uncertain.

Dr. George Kiddoch

said he had been impressed by the results of Mr. Bankart's operations. He
would have liked to hear more of the methods of preventing contractures
in spinal cord lesions, and pointed out that in such lesions there was a period
of flaccid paralysis before the spasticity came on; during the former period
treatment by splintage, &c., should be instituted to prevent the occurrence of
contractures during the latter period. When the reflex arc was being restored
slight stimuli frequently resulted in spasm and must therefore be avoided.

Mr. E. Muirhead Little

said he regretted that he had had no personal experience of Stoffel’s operation.
It had been his practice to treat spastic palsy on the lines outlined by the
President, with satisfactory results when the patient’s intelligence was adequate.
Foerster laid down as necessary conditions for his operation the existence of
severe spasm and good intelligence. Of course this combination was very
rare, but he had had one such case in which the operation cured the spasm,
but the patient seemed to have no power of balance and when last seen could
not walk alone. It should be remembered that in spastic paralysis the whole
muscular system was generally involved, including even involuntary muscular

Little—Evans—Fairbank

tissue. This was shown by the absence of any bleeding of importance during
and after extensive myectomies and the almost constant complication of
constipation. Staffers method, if not an ideal one, represented in his opinion
a great advance.

Mr. E. Laming Evans

referred to four cases of posterior root section which he had performed upon
cases of spastic paraplegia and had reported to the International Congress of
Medicine in 1913. The ultimate results were not encouraging, and rhizotomy
could not be classified as a routine operation for the relief of spasmodic
muscular contracture. He pointed out that the treatment of spasmodic
muscular contracture by exsection of the obturator nerve was long antecedent
to Stofifel, and that the division of branches of the other motor nerves after
they had left their parent trunk was but an extension of the principle of that
treatment, and was not Staffers method, which consisted in division of nerve
fibres in the trunk itself. He had never performed a true Stoffel's operation,
he had preferred a freer dissection, and the exposure of the muscular branch
after it had left the parent trunk. The proof of specific muscular branches by
electrical stimulation was more certain. He had had success in overcoming
pronator spasm in hemiplegia and adductor spasm in spastic paraplegia.
Where adaptive shortening had occurred he thought it necessary to perform a
plastic operation upon the tendon : he had combined this with neurectomy in
cases in which severe spasmodic contracture was still present. He thought
splints and retention apparatus would still be required, especially in dealing
with the spasm of the hemiplegic hand. Tendon transplantation had proved
useful in restoring muscular balanoe. Re-education was essential after all
methods of treatment.

Mr. H. A. T. Fairbank

said he did not entirely share Mr. Bankart’s optimism with regard to the
Stoffel operation. A method, or combination of methods, must be selected
for each case. He asked Mr. Bankart’s opinion as to the most suitable age
for operating. Personally he thought that if the child could sit up and at
least make an attempt at walking, operation on the legs might be done at the
age of 3 years. With regard to the arm he was not sure whether delay to the
age of 6 years or more was not advisable. Cases of patients aged 10 to 14
years were much more difficult to deal with. In spastic equinus secondary
contracture should be sought for, and if present open lengthening of the tendo
Achillis done. If the equinus was purely spastic the case was suitable for
Stoffel’s operation. He had yet to learn that the Stofifel operation on the
internal popliteal nerve gave any better results than open tendon-lengthening
when properly done. In older cases it might bp necessary to combine the
two operations. In valgus cases he had obtained some good results by
several methods, including Stoffel's, and many unsatisfactory results. He
usually exsected half the nerve supply to the peronei, exposing the various
branches by a long incision, and not tackling the external popliteal nerve
itself, as Mr. Bankart had done. The Stofifel operation gave good results in
flexion of the knee, but here again the older cases required tenotomy of the
hamstrings in addition. For adductor spasm the Stofifel operation was
undoubtedly good. When both branches of the obturator nerve required
resection, he preferred the abdominal extraperitoneal route, which was easy and

Section of Orthopaedics

well removed from sources of infection. For inversion of the leg he had
usually done Jones’s operation, but had once exsected portions of the superior
gluteal nerve through a vertical incision above the trochanter with satisfactory
result. In the arm the paralytic element as opposed to the spastic was often
marked, and accounted for the disappointing results. Operation on the median
nerve had not given good results. In certain cases he favoured more extended
trial of transplantation. For instance, when voluntary power in the extensors
was very feeble and there was marked spasm of the flexor carpi ulnaris,
this muscle should be grafted into the extensors of the fingers rather than
entirely wasted by division of its nerve supply. He had tackled the nerve supply
to this muscle in three cases without much satisfaction. He usually attacked the
motor nerves after they had left the parent trunk rather than the trunk itself.
He would like to know whether Mr. Bankart thought it necessary to exsect
more than three-quarters of an inch of the nerve fibres when only a portion of
a branch was being removed. In a young child it was difficult to split the
nerve for any distance on account of the small size of the branches. He
agreed as to the disappointing results following Foerster’s operation—an
operation attended with a considerable mortality. He did not agree that
splints were unnecessary : after treatment of equinus he used rectangular “ tin
shoes ” with boots wedged on the inner side. Some of the older cases with
flexion of the knee required walking-irons for a time.

Mr. Rocyn Jones

said that from his limited experience he agreed almost entirely with what
Mr. Bankart said about the value of Stoffel’s operation for spasticity in the
lower limbs, but for the upper limb he was not sure that Stoffel’s operation
was the best surgical procedure. It was only in the lesser degrees of spasticity
that any improvement of function could be expected to occur in the arm, and
he had not seen any great benefit when Stoffel’s operation had been performed.
Tendon transplantation seemed to him a better operation, performed as for
dropped wrist in irrecoverable musculo-spiral paralysis, i.e., attaching the pro¬
nator radii teres to the carpal extensors, the flexor carpi radialis to the
thumb extensors, and the flexor carpi ulnaris to the extensors of the fingers.
There had been far greater improvement under this operation than by the use
of Stoffel’s. As for spasticity in the lower limbs, Stoffel^s operation in the
main was much the best, but he rather favoured elongation of the tendo
Achillis as well: this was done subcutaneously with subsequent splinting,
the foot being kept at right angles and the knee extended. Hamstring and
adductor spasm were sufficiently relieved by Stoffel’s operation alone.

Mr. Gordon Pugh

asked whether Mr. Bankart or any of the neurologists present had had experi¬
ence of decompression in cerebral spastic paralysis. He referred to the work of
Wyeth and Sharpe, who reported favourably on the operation in cases resulting
from birth traumatism and showing an existing increased intracranial pressure
on ophthalmoscopic examination confirmed by lumbar puncture. The aim was
to relieve the pressure on the cortex of the cyst-like formation which resulted
from the primary supracortical haemorrhage. Cases in which the condition
was due to lack of development of the brain or to meningitis were not operated
upon. In a series of 1,026 patients examined one in every four had shown

Pugh —Bristow—Feiling—Elmslie

definite signs of increased intracranial pressure. These cases, 236 in
number, ~aged between 2 and 6 years usually, had been decompressed;
twenty died and thirteen showed no improvement, but the results in the
others were stated to have been very satisfactory both physically and
mentally.

Mr. W. Rowley Bristow

said that he agreed with Mr. Bankart in the main, and pointed out that he
was the first among the orthopaedic surgeons in London to popularize Staffers
operation. He said that in his experience it was always safe to divide com¬
pletely both branches of the obturator nerve, and that he himself preferred to
divide it above the foramen by the extraperitoneal route. He suggested .feh&t
the division of some nerves—for example, the superior gluteal—was not always
very easy, particularly in a fat subject. He further pointed out that it was
unwise in the present state of knowledge to make definite statements about
individual nerve division, as the whole subject was still fairly recent, and the
results largely depended upon the experience of the individual surgeon. Because
a man was overcoming a spastic equinus to-day by elongating the tendo
Achillis, it did not necessarily follow that he would be wise in continuing this
if he found that division of the tract in the internal popliteal nerve gave as
good, or better, result. He thought that more investigation was required, and
expressed himself as very hopeful of the results of this operation, which he
regarded as being of wide application.

Dr. A. Feiling

said he would discuss the subject briefly from the neurologist’s point of view.
He had had the privilege of seeing some of Mr. Bankart’s cases, and Mr.
Bankart had operated on cases for him. He was glad to hear that the
majority of opinions seemed to condemn Foerster’s operation for the relief of
spastic paralysis in children. The results he had seen were very disappointing,
and entirely out of proportion to the severity of the operation. Hence Stoffel’s
operation, as described by the opener of the discussion, was to be welcomed.
He was sorry that Mr. Bankart had not included for consideration other forms
of spastic paralysis besides the cerebral palsies of children, for in selected cases
he felt sure that there was a field for usefulness for the Stoffel operation. In
selecting cases, however, for this form of treatment two important principles
should be borne in mind. First, the diagnosis must be clear both as to the
pathological cause of the disease as well as of the anatomical site of the lesion.
And, secondly, the lesion must not be a progressive one. He concluded by
briefly describing a case of spastic paraplegia in an adult female, the subject
of the chronic spinal type of disseminated sclerosis, in whom Mr. Bankart had
brought about very considerable relief by means of carefully designed opera¬
tions on the peripheral nerves. In this case, from being bedridden with the
legs in a state of spasmodic flexion, the patient had been provided with
two straight legs, stiff it was true in extension, but capable of serving as
useful props.

Mr. E. C. Elmslie

pointed out the necessity for accurate diagnosis before operating, as he had
operated, naturally without benefit, upon two cases of congenital syphilis.
Since then he had had the Wassermann reaction performed upon all cases.

Section of Orthopaedics

He thought it would be a mistake to scrap the old operation, especially in the
case of the calf muscles, on account of the difficulty of judging the proportion
of the nerve to exsect. He asked whether flexion at the hip and knee were
not interrelated, and what could be done for contracture of the psoas. He
advocated re-education after Stoffel’s operation.

Mr. Naughton Dunn

said that they were apparently all agreed that the most effective operative
treatment to overcome spastic deformities was by direct operation on the
muscles or their motor nerves. About the same time as Stoffel was doing
his original work he had operated on a series of cases of spasmodic flat foot
by crushing the motor nerve branches of the peroneal muscles. The results
were excellent in that the patient walked early without splintage, and during
temporary paralysis of the peroneal muscles the invertors of the foot had an
opportunity of developing and restoring the arch. In spastic paralysis,
however, the problem was complicated, as Dr. Riddoch had pointed out, by
the fact that the extensors of the limb were, in the severer cases, also in a
state of hypertonus, and their range of voluntary control was limited. He
could hardly believe that Mr. Bankart would dispense with splintage and
re-education in these cases. The main point he wished to emphasize was that
the prognosis in spastic paralysis depended on the degree of voluntary control
of the limb rather than on the particular operation performed to overcome the
spasm of the muscles responsible for the deformity. The other point to which
he wished to draw attention was the fact that occasionally flexion of the knee
and equinus deformity of the foot might be secondary to simple adductor
spasm. This could be demonstrated by seating the child on a table and
observing that voluntary extension of the knee and dorsiflexion of the foot
were present. In these cases the knee flexion and the equinus were assumed
by the child in order to make locomotion possible in the presence of adductor
spasm, so that only operation to overcome the latter was necessary. Mr.
Bankart had given a careful and interesting review of the treatment of a very
difficult type of case.

Mr. P. Jenner Yerrall

said he had had good results from Stoffel’s operation in the legs of spastic
children, but not in the arms of adults. He had successfully treated flexion
at the hip by section of the psoas at its insertion, leaving the iliacus intact.

Mr. Bankart (in reply)

said that Dr. Riddoch was talking of recoverable lesions, while he (the speaker)
had devoted his paper to permanent conditions in which contracture would
recur, even after prolonged splintage, as soon as the splints were removed. He
agreed that Stoffel was not the first to divide the obturator nerve for adductor
spasm, but he was the first to formulate a definite plan of treatment by
neurectomy for spastic paralysis, and it was the best treatment that had yet
been devised for physiological contracture. When there was anatomical
shortening the muscle must be attacked directly, and he sometimes combined
this measure with nerve section. In the actual section of the nerve there was
a tendency to do too little rather than too much. He divided both divisions
of the obdurator nerve in the thigh, and personally was disinclined to perform

42 Bankart: Operative Treatment of Spastic Paralysis

the abdominal operation. There were no age-limits for the operation, but he
rarely saw cases younger than 2 or 3 years of age. The true Stoffel operation
was carried out upon the main nerve trunk and not upon nerve branches.
He had had no experience of decompression in this class of case. He doubted
the value of such a procedure when spastic paralysis was well established.
He never used splints after StofTel’s operation, except when this was combined
with operation upon the muscles or tendons. He agreed that some after-
treatment might be beneficial, but he emphasized the fact that after Stoffel'8
operation prolonged after-treatment and particularly the use of cumbersome
walking instruments were entirely unnecessary.

Section of ©rtbopaefcico.

President—Mr. T. H. Openshaw, C.B., C.M.G., M.S.

Four Cases of Flexion Contracture of the Forearm
treated by a Muscle-sliding Operation.

C. Max Page, F.R.C.S., M.S.Lond.

I HAVE now operated on ten cases by this method. In the last few I have
carried out the most complete operation and up to date the results in these
appear to be the best.

The technique is as follows: A skin incision is made from 3 in. above
the inner condyle on the line of the ulnar nerve to the inner side of the
subcutaneous border of the ulna at the junction of the middle and lower thirds
of the forearm. The ulnar nerve is first isolated at the level of the elbow and
transposed to the front of the joint out of harm's way. The attachments of the
whole flexor group of the forearm are then systematically detached from their
origin, the supracondylar ridge cleared and the common tendon cut close to the
internal condyle and stripped from the lateral ligament, the elbow-joint being
usually opened at this stage. Next, the aponeurosis on the ulnar side of the
ulna is cut through in its whole length close to the bone. The muscle mass so
loosened is raised with a raspatory ; any definite tendinous origins below the
coronoid process of the ulna are divided, the insertion of the brachialis anticus
being fully exposed. If the flexor longus pollicis is contracted the process of
muscle-stripping is carried across the interosseous membrane, so that the
attachment of the thumb flexor to the front of the radius can also be raised.
Lastly, the bicipital fascia is cut through if it appears to offer any opposition
to the descent of the muscle group. If care is taken to keep close to the bone
no important vessels are divided, and no damage can be done to any nerve
except the anterior interosseous and the terminal part of the internal cutaneous.
The separation of muscles and fascia is carried out to such an extent that
nearly full correction of the contracture, apart from phalangeal joint deformities,
is possible at once. The whole muscle group will be made to descend an inch
or more from its origin. The hand is put up in the corrected position on a
metal splint, which is replaced in a few days’ time by a properly fitting
plaster mould.

Voluntary control of the mobilized muscles is lost or becomes very weak
for a few days after the operation, and is then gradually recovered. The

AU—Ob 1 [Apr»i 17, 1923.

Page: Flexion Contracture of the Forearm

plaster mould is worn for most of the day during muscle re-education, so as to
enable the extensors to recover tone and become effective opponents. Careful
splintage and the usual physiotherapeutic measures must be employed in order
to complete the cure.

Case I: Flexion Contracture of the Eight Forearm. —History: Gunshot wound
right arm, 1917, followed by complete paralysis in distribution of the median nerve
below the wrist. In 1920 an autogenous graft on the median nerve was attempted.
Treatment subsequently by splintage and massage to correct contracture of the flexor
muscles.

State on November 27, 1922: Anaesthesia in median nerve distribution, no faradic
response in median intrinsics. The thumb, index and middle fingers were held flexed
at the interphalangeal joints and could not be passively or actively extended.

Operation on November 30, 1922 : The ulnar nerve was displaced forward; the
flexor group of muscles was then completely detached from its origin including
the deep attachments of the flexor sublimis and profundus digitorum and flexor longus
pollicis. The fingers were kept straight on a splint for four weeks, only being removed
for massage. Still under treatment. Contracture corrected. Function of the hand
good.

Case II: Flexion Contracture of Forearm associated with Injury to the Ulnar
Nerve. —History: Gunshot wound left elbow, August, 1918, followed by ankylosis of
left elbow and partial lesion of the ulnar nerve. The ulnar nerve was sutured in 1920.

State on July 18, 1922 : No faradic reaction in ulnar intrinsics; ulnar sensory loss.
Contracture of all fingers of left hand. Thumb normal.

Operation on August 8, 1922 : Ulnar nerve explored ; a 5-inch gap was present; on
account of elbow fixation no attempt was made to repair this. The flexor group
of muscles, except flexor longus pollicis, was detached from its origins and the
contraction of the fingers corrected. Except when removed for massage the hand was
kept extended until December 12, 1922, after which the splint was only worn at night.
Contracture corrected. The function of the hand is good, taking into consideration the
complete loss of conduction in the ulnar nerve.

Case III: Flexion Contracture of Forearm secondary to Ischaemic Paralysis. —
History: Gunshot wound arm, 1917; no injury to bone or nerves. Treatment by
splintage was carried out for a year.

State on September 2, 1922: Obstinate flexion contracture of all the fingers of the
right hand. Electrical reaction to the median and ulnar nerves normal.

Operation on September 7, 1922: Ulnar nerve transposed, the attachments of the
flexor group, except flexor longus pollicis, were detached, allowing of correction of
the deformity. The hand was put up in full extension five weeks. The correction
of the contracture is not quite complete. The hand is fairly useful but the movements
of the fingers are not fully independent.

Case IV : Flexion Contracture of Forearm folloiving Hemiplegia. —History :
Gunshot wound of the head, 1918, followed by hemiplegia from which there was
gradual recovery in the leg and partly in the arm. The flexors of the forearm of the
right side remain contracted. Massage and splintage treatment of deformity carried
out for several years.

Operation on March 13, 1922 : The common origin of the flexors was divided and
some of the deep attachments were also separated. The flexor longus pollicis origin
was not touched. The hand was kept in the fully extended position for three weeks
after operation. The result is not very satisfactory; there is fair correction of the
deformity but the control of the fingers remains inco-ordinate.

Section of Orthopaedics

DISCUSSION.

Mr. Whitchurch Howell found the operation useful when the scar was above
the elbow, but when it was below that joint he preferred to excise the scar in the
muscles.

Mr. Rowley Bristow thought the operation was useftil in selected cases where
there was no contracture of the capsule in the finger joints.

Mr, T. H. Openshaw (President) said that in similar cases he excised the scar
tissue, not once only but sometimes three times, and gradually got the fingers and
wrist into good position by plaster of Paris splintage and massage. If the nerve
was injured it should be resected and end-to-end suture obtained. The scar and the
nerve injury should be dealt with as separate conditions. He also thought that when
the injury was in the forearm, detachment of the flexors from the internal condyle
would not relieve the contracture.

Mr. Max Page (in reply) said he did not think that the local excision of scar was
a very satisfactory procedure in the type of case he had shown. In these instances,
there was for various reasons a general shortening of the muscles of the forearm.
The procedure he put forward was a substitute for general tendon lengthening; it had
the advantage over the latter operation of not interfering with the normal independent
movement of the tendon. As could be seen in the cases he had shown, the flexor
muscle group became securely fixed again soon after operation without any material
interference with muscle function and yet gave sufficient lengthening to allow of the
correction of considerable deformity.

Case of Renal Dwarfism shown after Operation for

Genu Valgum.

By Paul Bernard Roth, F.R.C.S.

K. A. P., AGED 13, sent to me by Dr. Maurice Davidson; very small for
her age, thin and sallow, with extreme genu valgum (10 in. between malleoli),
enlargement of internal condyles, and characteristic urine (pale, specific gravity
1005, albumin one-half on boiling and standing). Radiogram: Internal con¬
dyles enlarged, spongy looking transparent bone, and patohes here and there
in diaphysis where bone appeared almost missing. Lower ends of ulnae
similar.

The urea concentration test was applied. If 15 grm. urea are given by
mouth the percentage of urea in the urine and in the blood two hours later
should be normally 2 and 0'03 respectively; the normal urea concentration factor
(i.e., percentage of urea in the urine, divided by that in the blood) is thus 66'6,
the kidneys concentrating the urea 66'6 times. In the case shown, the test
was made in June, 1922, and repeated in January, 1923. The percentage of
urea was 0'9 and 0'8 respectively in the urine, and 0*091 and 0*124 in the
blood; the urea concentration factor was thus 10 and 6*45 respectively. In
other words, her kidneys last January were only doing one-tenth of the urea
concentrating work they should be doing, and the condition had become worse
notwithstanding the rest in bed. As the patient was completely crippled,
however, double supracondylar osteotomy was performed in February under
gas and oxygen. Nothing untoward resulted.

46 Roth: Ocular Torticollis; Howell: Snapping Hip

Case of Ocular Torticollis.

By Paul Bernard Roth, F.R.C.S.

D. T., AGED 8, was sent up by the L.C.C. school medical officer as a case of
wry-neck; with history of having had wry-neck from birth and of having
attended Paddington Green Children’s Hospital when 3 months of age to have
massage applied to the right side of neck.

On examination it was observed that, though the patient carried her head
laterally flexed to the right, there was no shortening of the right sternomastoid
muscle, and that she was wearing badly centred glasses. She was sent to see
Mr. Hine, who reported that this was a case of true ocular torticollis, due to
a left convergent strabismus. He has now corrected this by suitable glasses,
and patient is being trained to hold her head straight and is improving rapidly.
Mr. Hine remarks: “With glasses off left eye is markedly up with head
straight, and comes into middle of palpebral fissure when head is turned over
to right. It is rather difficult to explain this, but there is no doubt the glasses
correct it. I suppose holding the head over to right tends to set up a natural
impulse to pull left eye down to bring eyes a bit more level/*

DISCUSSION.

Mr. A. B. Bankart said that in view of the history he had obtained from the
mother he regarded the case as one of ordinary torticollis in which the contracture of
the sternomastoid had been overcome by the. massage which had been applied during
two-and-a-half years’ attendance at the Children’s Hospital in infancy.

Mr. H. A. T. Fairbank said he had seen two cases of ocular torticollis in the last few
years, and these closely corresponded with the case shown. There was no change in the
sternomastoid, and if the child were told to follow the finger the axes of both eyes
remained directed at the finger until it passed over to the right side when that of the
left eye would aim upwards and to the right. This served to differentiate these cases.

Case of Snapping Hip.

By B. Whitchurch Howell, F.R.C.S.

Patient, a cellarman, sustained a gunshot wound of the left buttock in
March, 1918, and this was followed by a snapping right hip. The entrance
scar is in the middle line of the buttock, just above the gluteal fold, and the
small exit scar in the groin over the origin of the adductor. There is also an
elliptical scar from well below the anterior superior iliac spine to the junction
of the upper and middle thirds of the thigh, indicating an operation for snap¬
ping hip performed at Headington by Mr. Girdlestone in July, 1918. There is
wasting of muscles of left lower limb without actual shortening ; full range of
knee movement with definite lateral mobility, especially on inner side; and
slight limitation of flexion at hip. X-ray negative. The snap appears to be
due to the slipping of the gluteus maximus over the great trochanter, and is
not connected with the tensor fasci© femoris. There is no apparent tele¬
scoping. The joint is very insecure, so that patient is unable to lift barrels, &c.
Opinions are desired as to the best treatment.

Section of Orthopaedics

Case of ? Charcot’s Knee.

By H. A. T. Fairbank, D.S.O., M.S.

H. W., male, aged 48. Broke right patella in 1914. Wired. Wire since
removed. Had trouble in left knee in 1916; excised at Guy’s Hospital.
Complains of insecurity of right knee. No pain.

Eight knee shows great enlargement of bones; marked varum deformity
with obvious ulceration of articular surfaces. Abnormal mobility very marked.
Very little excess of fluid. X-ray shows gross changes in joint with loss of
bone on the inner half of the joint and enormous development of nodules of
bone in and around the joint.

Left knee shows excellent result of excision, with bony ankylosis.

Eyes : Pupils react slowly to light.

Knee-jerk present on right. Plantar reflex-flexion both sides.

Wassermann reaction negative.

Should this knee be excised ?

The general opinion expressed by speakers in discussion was in favour of excision,
as even if bony union did not occur the straightened knee would be much easier to
control by apparatus.

Case of Dislocation of Patella outwards, secondary to
Osteomyelitis of Femur.

By H. A. T. Fairbank, D.S.O., M.S.

F. W., BOY, aged 6. History: Operated upon when 7 weeks old for
“ cellulitis ” of left leg. First seen April, 1922, with marked genu valgum and
outward dislocation of patella, there being a thick scar on the outer side
adherent to lower third of femur. April 27, 1922 : Excision of scar. May 24,
1922 : Osteotomy on left femur for correction of knock-knee. Position of
patella much improved, but later found to be going outwards again, with
strong tendency to relapse to condition of genu valgum. X-ray shows some
slight thickening of lower third of femur with epiphyseal line apparently
normal. Patella not ossified.

The genu valgum and tendency to relapse to this state are regarded as due
to the scar rather than to previous damage to the outer part of the epiphyseal
line. In view of the strong tendency to genu valgum opinions are asked as to
the best time for operating on the displaced patella.

The general opinion expressed by speakers in discussion was in favour of operating
on the displaced patella soon.

Perkins: Pseudo-Coxalgia in an Adult

Case of Pseudo-Coxalgia in an Adult.

By G. Perkins, M.Ch., F.R.C.S.

PATIENT, a male, aged 22, sought advice on account of slight pain in his
left leg. The onset of the pain was insidious, and the duration about six
months. He had never before, to his knowledge, had anything the matter
with the leg, although his tailor had told him two years ago that it was short.

On examination of the left hip, tenderness was found over the head of the
femur on palpation. The hip at rest was slightly everted ; there was no
adduction deformity or fixed flexion. All movements were limited in the outer
half of their range, but throughout the inner half they were painless and free.
The amount of true and apparent shortening was 1| in., and the trochanter
was correspondingly raised. The radiogram showed well marked flattening
and widening of the head of the femur. No arthritic changes could be seen,
and the interarticular space was of normal depth.

The patient was an athlete; and during the week before the consultation
had danced two whole evenings, and had played a game of Rugby football.

Section of ©rtbopa&ics.

President—Mr. T. H. Openshaw, C.B., C.M.G., M.S.

Case of Intracapsular Fracture of the Neck of the Femur.
By R. C. Elmslie, O.B.E., F.R.C.S.

Dr. E., aged 69, fell on September 22, 1922, sustaining an intracapsular
fracture of the left femur. Next day, under an anesthetic, the hip was
abducted, rotated inwards and fixed in plaster of Paris from the toes to the
pelvis, with a wing of plaster up the right side of the chest to prevent the left
hip adducting. The plaster remained on until November 18. After this,
massage movements and re-education were commenced in bed, and the patient
began to walk on the limb at the end of three months from the date of the
fracture.

X-rays taken April 4, 1923. show sound bony union with slight coxa vara
deformity. There is good range of movement in the hip joint; the walk is
almost natural and the patient is able to walk considerable distances and get
up and down stairs without difficulty.

Further X-rays were shown of a second patient, a woman aged 43, who
sustained an intracapsular fracture on April 9, 1922: she was treated on
exactly similar lines, and she walks with a slight limp with very good
functional use, except for a considerable coxa vara deformity, which limits
abduction of the hip.

Case of Osteitis Deformans.

By Paul Bernard Roth, F.R.C.S.

Mrs. S. H., aged 61, was sent to me on April 27, 1922, by Mr. Ell wood.
Patient informed me that the right leg had been bending outwards below the
knee for fifteen years or more, but that during the last two to three years the
bend had become much worse. “ The bone seemed to bend under her.”
There was a large amount of pain attached to it. Though she was more or
less relieved by rest, quite often, even when in bed, the pain would come on
very badly and keep her awake; it was a dull, aching pain, much worse in
windy weather. She was now scarcely able to walk about her home because
of the pain, and hardly ever went out. The pain, bend, and weakness were all
increasing.

During the last year the left leg had begun to go in the same way; the
condition had begun acutely, “ as if she was going to have an abscess in the

[May 1, 1923.

50 Roth: Osteitis Deformans; Howell: Tendon Transplantation

leg.” She had attended a hospital and had been advised a year ago to have
the right leg cut off.

Examination .—Right leg: Typical osteitis deformans. Tibia much en¬
larged, and bowed forwards and outwards, the curve forming one-fifth of the
circumference of a circle. Left leg: Tibia upper half was enlarged anteriorly.

Before operation.

After cuneiform osteotomy showing bony union.
Osteitis deformans of right tibia.

I decided to perform cuneiform osteotomy of right tibia, and then to apply
a walking instrument. Operation carried out on June 7, 1922, and plaster
applied. Plaster removed on June 20, 1922, and tin night shoe applied*:
union had already begun.

October 6, 1922 : Fitted satisfactorily with Thomas’s calliper knee splint.

April 20, 1923: Very good bony union with leg straight; walked about fin
house for three hours a few days ago with splint off without discomfort.
X-ray shows sound bony union.

Case of Tendon Transplantation.

By B. Whitchurch Howell, F.R.C.S.

W., AGED 31, sustained a gunshot wound of the left arm in June, 1917,
which caused musculo-spiral paralysis. The nerve was sutured in the
following September, and recovery followed, except in the extensor longus
pollicis.

Section of Orthopaedics

In January, 1923, the flexor carpi radialis was inserted into the extensor
longus pollicis, which was freed from its groove in the radius and divided
transversely, a direct subcutaneous pull being thus obtained. The limb was
placed in plaster of Paris with the wrist hyper-extended, and early treatment by
faradism and re-education adopted.

DISCUSSION.

Mr. D. M. AlTKEN congratulated Mr. Howell on the excellent result which had
followed his boldness in taking the tendon out of its groove to obtain a straight pull.

Mr. T. H. OPEN8HAW (President) regarded the operation as a distinct advance.

Case of Renal Dwarfism.

By W. H. Ogilvie, M.S.

P. M., AGED 17, motor apprentice. History: Only child. Has always
been considered small for his age, but learned to walk and talk at the usual
time, and at school was good at lessons, and played cricket and football.
Suffered from children’s complaints, but no history of illness involving more
than a week in bed. His head has always been square. He first noticed
stiffness in his knees in 1921, but was able to walk, and began work as an
apprentice. In June, 1922, he tripped on a platform while going to work, and
sprained his ankle. He was in bed for a week, and when he got up was
unable to walk. Since then he has never walked without assistance, but has
been better during the last fortnight. He suffered from nocturnal enuresis till
the accident, but since then this has disappeared.

Present condition : Boy very small for his age, looking about 12. External
genitalia well developed, but pubic hair scanty, and voice childish. Muscular
development very poor; very little subcutaneous fat. Skeletal system : Head
square. Obvious enlargement of all epiphyses, most marked at ankles and
wrists. Marked genu valgum, tibiae making an angle of 30°; this has
developed during last two years. Movement at joints little affected, but flexion
at ankle, extension at knee, and abduction at hip all slightly limited. Reflexes
all normal. Blood-pressure: Diastolic, 70, systolic, 122. Urine: Strongly
alkaline, containing pus cells and triple phosphates ; specific gravity, 1009 ;
albumin 2 per 1,000, no sugar, no casts. Bacillus coli communis in large
numbers. Blood urea: 2*7 gr. per 1,000 cubic centimetres, or nine times the
normal amount. Wassermann reaction negative. Gait: Will not walk
without support, and then only stiffly and slowly.

X-rays: Kidneys show no evidence of calculi; all epiphyseal spaces wide
and ragged in outline ; no cupping of diaphyses.

The history and appearance are typical of a renal dwarf. There is probably
a functional element in the inability to walk.

Specimen of Synostosis of Phalangeal Joints
? Congenital in Origin.

By W. H. Ogilvie, M.S.

SOURCE : The skeleton of a hand shown is from an anatomical subject in
the dissecting room at Guy's Hospital. A similar condition was present in the
other hand, but not in the toes of the feet. The body was that of a man aged
58, who died of “ cardiac failure and chronic bronchitis.”

52 Ogilvie: Specimen of Synostosis of Phalangeal Joints

Description : The thumb is normal. The first interphalangeal joint of the
index appears normal, but only a limited amount of flexion is possible. The
first interphalangeal joints of the middle, ring, and little fingers are completely
ankylosed. In addition, the second phalanx of the little finger is only 3 mm.
long, so that the tip of the distal phalanx only reaches just beyond the first
interphalangeal joint of the ring finger, instead of to the second joint. In the
wrist, the os magnum and unciform bone are fused.

X-rays (with specimen) show the above abnormalities. No evidence of
arthritis.

Points of interest: In the circumstances, no history was obtainable. There
is no evidence of rheumatoid arthritis in the other articulations of the hand,
while the remaining joints in the body appeared normal. The shafts of the
bones show neither thickening round the articular margins, nor atrophy.
They are well formed, and at the joint-line show a contour resembling that of
the head and base of the corresponding phalanges. There is no ulnar deviation
at the metacarpo-phalangeal joints.

Is this an old arthritis, or a congenital condition ? The fusion of bones in
the wrist suggests a congenital condition.

PROCEEDINGS

OF THE

ROYAL SOCIETY OP MEDICINE

EDITED BY

Sir JOHN Y. W. MacALISTER

UNDER THE DIRECTION OF

THE EDITORIAL COMMITTEE

VOLUME THE SIXTEENTH

SESSION 1922-23

SECTION OF OTOLOGY

LONDON

LONGMANS, GREEN & CO., PATERNOSTER ROW

1923

Section of ®tolog\>.

OFFICERS AND COUNCIL FOR 1922-23.

President —

Huntek F.Tod, F.R.C.S. [died March, 1923], February, 1923,
after which Sir CHARLES Ballance was elected President.

Vice-Presidents —

Sir Charles Ballance, K.C.M.G., C.B., M.V.O., M.S-
A. H. Cheatle, C.B.E., F.R.C.S.

G. William Hill, M.D.

A. J. Hutchison, M.B.

J. F. O’Malley, F.R.C.S.

Andrew Wylie, M.D.

Hon. Secretaries —

F. J. Cleminson, M.Ch.
Archer Ryland, F.R.C.S.Ed.,

Other Members of Council —

Lionel Colledge, F.R.C.S.

J. S. Fraser, F.R.C.S.Ed.

A. A. Gray, M.D.

W. J. Harrison, M.B.

B. Seymour Jones, F.R.C.S.

H. Buckland Jones, M.B.

Hugh E. Jones.

Norman Patterson, F.R.C.S.
Henry Peterkin, M.B.

T. Ritchie Rodger, M.D.

Sydney Scott, M.S.

Herbert Tilley, F.R.C.S.

A. Logan Turner, M.D.

George Wilkinson, F.R.C.S.

R. A. Worthington, O-B.E., M.B.

Representative on Library Committee _

Somerville Hastings, M.S.

Representative on Editorial Committee—
H. J. Banks-Davis, M.B, F.R.C.P.

SECTION OF OTOLOGY

CONTENTS.

October 20, 1922.

Somerville Hastings, M.S., and Major W. S. Tucker, R.E., D.Sc. pagk

An Attempt to Standardize Tests for Hearing ... ... ... 1

E. D. D. Davis, F.R.C.S.

A Temporal Bone from a Case of Tuberculous Lateral Sinus Thrombosis

and Extra-cerebellar Abscess ... ... ... ... ... 5

Sir James Dundas-Grant, K.B.E., M.D.

Case of Acute Suppuration in one Ear subjected to Early Operation on

Account of Complete Deafness of opposite Ear ... ... ... 6

Archer Ryland, F.R.C,S.Ed.

Case of Absolute Bilateral Deafness, with almost Complete Loss of

Vestibular Activity ... ... ... ... ... ... 7

G. J. Jenkins, F.R.C.S.

Tinnitus associated with Facial Spasm ... ... ... ... K

November 17, 1922.

Albert A. Gray, M.D.

Some Cases of Otosclerosis with an Unusual Symptom (Otosclerosis

Paradoxica) (Abstract) ... ... ... ... ... 9

T. B. Layton, D.S.O., M.S.

44 The Disease of not Listening, the Malady of not Marking ” (Abstract) 12
Cases and Specimens shown ... ... ... ... ... ... 14

January 19, 1923.

A. Logan Turner, M.D., and J. S. Fraser, M.B.

Labyrinthitis as a Complication of Middle-ear Suppuration (Abstract) ... 15

Sir James Dundas-Grant, K.B.E., M.D.

Case of Complete Nerve-deafness due to Syphilis of Internal Ears ;

Caloric and Rotation Tests Negative, Galvanic Positive ... ... 16

F. J. Cleminson, F.R.C.S.

Case of Otitis Media with Facial Palsy, following Scarlet Fever;

Specimens (Malleus and Incus) shown ... ... ... ... 17

Contents

Sir James Dundas-Grant, K.B.E., M.D. PAtiK

Case of Vertigo, with Fixation of the Ossicles, cured by Ossiculectoiuv 18
Norman Patterson, F.R.C.S.

Parotid Fistula following Mastoid Operations ... ... ... \\)

Sydney Scott, M.S.

Ossification of Incus to Tegmen ... ... ... ... *20

E. Lowry, M.B.

Case of Acquired Atresia of the Auditory Meatus ... ... ... 20

Sir James Dundas-Grant, K.B.E., M.D.

(ase of Vertigo (simulating “ M<5ni&re’s Disease ”) with Anomalous
Nystagmus Reactions... ... .. 20

February 16, 1923.

G. J. Jenkins. F.R.C.S.

Otosclerosis and Osteitis Deformans: A Pathological and Clinical
Comparison (Abstract) ... ... 21

J. F. O’Malley, F.R.C.S.

Case of Necrosis of the Left Temporal Bone, involving Facial Nerve and
Labyrinth, following Triple Infection of Scarlet Fever, Measles and
Diphtheria, in a Child aged 7 ... 20

H. J. Banks-Davis, M.B.

(1) Parotid Fistula in the Scar of an Old Mastoid Wound . HO

(2) Laceiation of Meatus and Tympanic Membrane produced by a

Celluloid Knitting Needle ... ;}n

March 16, 1923.

F. J. Clkminson, M.Ch. (Shown by).

Case of Acusticus Tumour (Right); Operation by Sir Victor Horsley in
1912 : Removal of Tumour; Recovery ... .. 31

F. M. R. Walshe, M.D. (Shown by). (Introduced by Mr. F. J. Clkminson).

Specimen of Brain and Acusticus Tumour ... 32

F. M. R. Walshe, M.D.

Acusticus Tumours ... ^

Wilfred Trottkr, M.S.

Surgical Treatment of Eighth Nerve Tumours (Abstract) ... ... 37

April 20, 1923.

E. D. D. Davis, F.R.C.S.

The Morbid Anatomy and Drainage of Otitic Meningitis
Sir James Dundas-Grant, K.B.E., M.D.

(1) Case of Complete Deafness dating from a Fall

(2) Case of Deafness greatly increased after a Fall

f3) Case of Long-standing Deafness attributable to Falls on the Head
Improvement

47
4 H

Contents

May 18, 1923.

Exhibited by W. M. Mollison, M.Ch. pagk

An Instrument for assisting the Deaf ... ... ... ... 51

Frederick Sydenham, F.R.C.S., and Dan McKenzie, M.D.

Epidemic Cerebro-spinal Meningitis associated with Acute Suppuration

of the Middle Ear ... ... ... ... ... ... 51

Dan McKenzie, M.D.

(1) Epileptiform Seizures subsequent to Operation for Temporo-

Sphenoidal Abscess ... ... ... ... ... ... 52

(2) Otitic Pterygo-maxillary Abscess induced by Thrombo-phlebitisof the

Jugular Bulb ... ... ... ... ... ... 53

T. H. Just, F.R.C.S.

Brain Abscess due to Otitic Infection; Right Temporo-sphenoidal

Abscess without Clinical Signs ... ... ... ... 54

Sydney 8cott, M.S.

(1) Left Temporo-sphenoidal Abscess; Amnesia for Names of Objects ... 55

(2) Cerebellar Abscess; Sudden Coma and Apncea; Recovery after

Operation during Artificial Respiration ... ... ... ... 56

(3) Cerebellar Abscess Five Weeks after Onset of Acute Otitis Media,

Right Side ... ... ... ... ... ... ... 57

W. M. Mollison, M.Ch.

Case of Vertigo cured by Opening the External Semicircular Canal ... 60

T. H. Just, F.R.C.S.

(1) Sequestra removed from the Region of the Eustachian Tube during a

Radical Mastoid Operation ... ... ... ... ... 61

(2) Section of Ependymal Glioma growing from the Floor of the Fourth
Ventricle, simulating a Cerebellar Abscess, in a Case of Bilateral

Chronic Suppurative Otitis Media ... ... ... 02

CORRIGENDUM.

Proceedings , No. 10, August, 1923 (Section of Otology, p. 57).

In Mr. Sydney Scott’s case of “ Cerebellar Abscess : sudden Coma and Apnoea :
Recovery after Operation during Artificial Respiration,’* lines 3, 4: instead of
“ Artificial respiration was applied and the operation stopped, but breathing remained
suspended,’ 1 read the following : “ Artificial respiration was applied, and the operation
continued , while breathing remained suspended.”

This correction was received too late for insertion.

The Society does not hold itself in any way responsible for the statements made or
the views put forward in the various papers.

otol. 2

London

John Bale, Sons and Lamelsson, Ltd.,
Oxford House,

83 91, Great Titchfield Street, Oxford Street, W. 1.

Section of ©toloop.

President—Mr. Hunter Tod, F.R.C.S.

Chairman—Sir Charles Ballance, K.C.M.G., C.B., M.Y.O., M.S.

An Attempt to Standardize Tests for Hearing.

By Somerville Hastings, M.S., and Major W. S. Tucker,

E.E., D.Sc.

(I) INTRODUCTION.

By Somerville Hastings, M.S.

Several years ago a Sub-committee of this Section spent a good deal of
time investigating the tests that are usually employed in the examination of
deaf people, and in endeavouring to determine which were of most value. 1
None of the methods usually employed for estimating the hearing power of an
individual, for instance the tuning fork, conversational voice, whisper,
acoumeter, appeared to be really satisfactory. They were all influenced by
the relation of the ear to the waves of sound, reflections from surrounding
objects and interference by extraneous sounds. Moreover, it is difficult or
impossible to maintain the same source of sound in different observations.

About three years ago Major W. S. Tucker, who has kindly come here
this afternoon, invited me to join him in trying to work out some better
method of the estimation of the hearing capacity. Major Tucker, whose
method of locating German guns by the sound of their firing had done so
much to win the war, was desirous of estimating the hearing capacity of
aeroplane listeners.

We have together tried a good many different methods, and the apparatus
we are showing to-day will need certain modifications to fit it for clinical use.
It depends on the following principle : A wireless valve can be made to give
out vibrations of any frequency ; the current from the valve passes to a
telephone and by means of a Wheatstone's bridge resistances are inter¬
posed until the sounds are no longer heard. Its advantages are: (1) That the
test is but little affected by slight extraneous sounds ; (2) that a pure sound of
any frequency and intensity can be obtained ; and (3) that the amount of
energy set free by it can be determined.

J. P. Minter, in the Physical Review of February, 1922, describes a
similar method, and gives extensive results but very few details of the
apparatus used.

As I am not a physicist, I think it best at this point to ask Major Tucker
to describe the apparatus to you in detail, and demonstrate the test on an
individual, after which, I shall briefly indicate some of the results we have
obtained by its use on deaf people.

Ja-Ot i

1 Proceedings, 1917-18, xi (Sect. Otol.), p. 4.

['October 20, 1922.

Hastings and Tucker: Tests for Hearing

(II) DEMONSTRATION OF STANDARD APPARATUS FOR TESTING

HEARING.

By Major W. S. Tucker, R.E., D.Sc.

One of the new operations required of the fighting services during the war
was that of listening for enemy aircraft. In general, the personnel for this
work was selected in a very casual kind of way, and the chief qualification
seemed to be the general unfitness of the men for any more strenuous occupa¬
tion. In the later stages, some crude tests were applied to select the best
men, but proficiency and intelligence in listening were not recognized by any
increase of pay. The installation now to be described was designed primarily
for testing such listeners, and it is hoped that there will be a listening qualifica¬
tion properly recognized—for it is an occupation requiring careful training,
skill and intelligence.

Our efforts towards producing a standard of good listening were brought to
the notice of Mr. Somerville Hastings, and his interest in the matter has
resulted in our modifying our designs, so that, if satisfactory, they can be
employed on the deaf.

The following considerations determined the form of this apparatus :—

(1) The sound must be that of a pure musical note for whatever part of the
scale the ear has to be tested.

(2) It must be reproducible, as regards pitch and intensity, from day to
day.

(3) There must be a logical scale of intensity.

(4) The signals conveyed to the ear must be intermittent at will, and some
indication of the listener, other than oral, must be such that no sound inter¬
feres with the process of listening.

(5) The sound should be produced so close to the ear that intensity of the
sound cannot be affected by reflections within the room.

(6) Outside disturbing sounds should be eliminated.

(7) The process of getting the limit of acuity should be a rapid one, to
prevent the subject from educating himself too well to the operation of
listening, or from losing acuity through fatigue as the result of concentrated
effort.

Since electrical methods are in general so well under control, an electrical
method was selected, and the sound was generated by an oscillatory electric
current actuating the diaphragm of a telephone.

Recent wireless research has presented us with an excellent generator of
oscillatory electric current. The electric circuit employed is shown in the
diagram exhibited.

The important constituent of this is the wireless valve, in which the space
inside is rendered a conductor of electricity by the particles or electrons emitted
from an incandescent filament. If a battery is used as a supply of current and
connected to a metal plate and to the hot filament in the valve, an electric
current will pass. If a metal wire screen be interposed between the filament and
the plate, the current will stop, but if in some way a small alternating voltage
be applied between the filament and this screen (called the grid)—the grid now
allows the current between the filament and metal plate to pass with very much
increased intensity. Here the grid and filament are connected by a coil of
wire, and the plate and filament are connected by what is called a tuned circuit
consisting of another coil with a condenser across its terminals. In this tuned
circuit we get a great readiness for electric current to be generated at a given

Section of Otology

frequency. A slight disturbance in this circuit reacts in the coil in the grid
filament circuit, producing an alternating voltage between filament and grid, thus
causing a large alternating flow between plate and filament, and since the tuned
circuit above referred to responds easily to this, oscillatory current in the
latter is thus built up to a high value, and can then be used to operate a tele¬
phone and produce a sound. For demonstration of this a loud speaking
telephone can be used.

The tuned circuit already referred to can have its note altered by varying
the condenser so that a range of notes can be obtained from 300 per second (G
above middle C of the piano) to some very high pitch only just distinguishable.
You will notice how pure the musical note is.

It would not be difficult to produce similar apparatus for getting the upper
limit of audition, but in this case it is difficult to get a pure note over so high
a range.

By altering the glow of the filament we can alter the loudness of the note,
so that the instrument is well under control. But if we keep the filament at a
steady glow, we do not get the same amount of oscillatory current for all
pitches, as can be seen in the diagram. We can, however, level out this curve
by altering the filament glow.

We thus have our oscillatory electric current. We now pass this current
into a Wheatstone bridge circuit in order to reduce it to a value suitable to our
requirements. The telephone used for the signal is the usual wireless head
telephone, with two receivers, and one of these is disconnected, so that the
sound only enters one ear, while the other is blocked up, and so is protected
from disturbing noises. When the bridge is in balance, there is no current in
the telephone and no sound. We alter the fourth arm of the bridge from its
balance value of 1,000 ohms resistance to 10,000, and the more we throw it
out of balance the louder is the sound. The diagram exhibited shows how the
sound intensity varies with the bridge reading.

When the subject is being tested he sits down with closed eyes, and he
places one hand on the table. Then the signal is put in the telephone by means
of a silent key, and if the subject hears he raises his finger, lowering it
when the sound ceases. We then reduce the sound till the finger just
fails to respond to the signal, and the acuity value is read off on the scale.

The apparatus before you shows the telephone circuit and key used in the
method thus described.

The apparatus however will do more than this. An arrangement is made
by means of which a disturbing sound of any desired pitch or intensity is main¬
tained in the signal telephone, and the signal is transmitted as before. A
new reading is thus obtained. In this way paracusis is tested and compared
between different individuals and for different ears.

With regard to the standardizing of the sound, an instrument is inserted
in the current generator for measuring the current output, and a definite
value for this current is laid down, so that the same sound can be repro¬
duced day after day.

Further, if the telephone has to be replaced by another, a method has been
devised for comparing it with the one previously used, and, in addition,
apparatus has been devised and is now being perfected for measuring the sound
in absolute units of energy, so that ultimately we hope to derive a measure
of that energy which is just capable of affecting the ear of any subject—
either deaf or of acute hearing—and of showing how this alters with age or
with varying physical condition. 1

1 The diagrams shown will be reproduced in a later communication.

Hastings and Tucker: Tests for Hearing

(III) RESULTS OBTAINED BY STANDARD APPARATUS FOR

TESTING HEARING.

By Somerville Hastings* M.S.

The results obtained by this apparatus have been extraordinarily constant.

Qualitatively they have agreed with the results obtained by other methods.
I mean that if a person hears better with one ear tested by tuning fork, voice, or
the acoumeter, he will hear better with the same ear tested by Major Tucker’s
apparatus. Quantitively the tests differ according to the type of deafness, as
we should expect.

We have made a good many observations on the effect on the same ear or
opposite ear, of a loud disturbing sound. We have found that in all types of
deafness examined, a disturbing sound in the opposite ear makes hardly any
difference in the power of hearing in the one being tested. If, however, the
disturbing sound is in the same ear, the intensity of the signal has to be
increased some seventeen to twenty-four times, before it is appreciated in the
case of a person with normal hearing. Cases of internal ear deafness and those
with perforation of the membrana tympani need eight or nine times the usual
stimulus.

In chronic catarrhal deafness we have found that most patients need an
increase in the intensity of sound of about nine or ten times, before it is perceived,
and one or two who had never noticed that they heard better in a noise needed
an increase of about five times. In the case of patients with paracusis who
were well aware they could hear better fin a noise, only from 1*7 to 2*3 times
the stimulus was required. We have never yet found an individual who could
really hear “ better in a noise.”

DISCUSSION.

Dr. WILLIAM Hill considered that the instrument would be very valuable, and
the exhibitors were to be congratulated on the clear exposition they had given. He
supposed that in perfecting the instrument for the use of the profession it could be
made fool-proof.

Dr. Logan Turner said he understood that when the buzzer was placed against
one ear, the hearing in the other ear was not diminished. When experimenting with
Bar&ny’s noise apparatus on a normally hearing individual, he had found the hearing
in the non-obstructed ear slightly reduced from the normal. The apparatus now
demonstrated possessed an advantage in this respect.

Mr. G. J. Jenkins also congratulated the exhibitors on this valuable piece of work;
it had been the want of otologists for many years, and many had tried to establish
some such standard. He had himself tried to do so by means of an induction coil,
getting a variation of intensity of sound by separating the two coils; but he found he
could not produce, by a mechanical apparatus, a make-and-break sufficiently rapid to
give more than 4,000 to 5,000 vibrations per second. He therefore turned his
attention to the valve referred to. A friend of his had been working at such apparatus
in Edinburgh for some time, but had given it up a short while ago, after hearing that
work on these lines was being done in America. There was no doubt that the present
apparatus did give a new test for hearing, and it would be advisable that the Section
should take an active interest in the matter, and help the workers to arrive at a
complete standardization. He asked the probable cost of the apparatus. It would not
take the place of tuning forks entirely.

Mr. Sydney Scott also expressed his interest in these investigations, which, taken
into consideration with those carried out in America by Dr. Gordon Wilson and others,
would yield important new data in elucidating problems of hearing.

Section of Otology

Mr. Somerville Hastings (in reply) agreed that the action of the buzzer in one
ear did not depreciate the hearing in the other ear. The padding of the ear-pieces
prevented any but the slightest bone conduction. The estimations were in terms of
energy. The normal was the average of a number of people with good acuity.

Major Tucker (in reply) said that an instrument for medical testing could probably
be produced for £15 or‘i-20. Listeners when employed for anti-aircraft work had to
come up to a certain standard which was based on an average of apparently normal
hearers. The instrument had shown great diversity in hearing between people
supposed to be normal. Subjects were also tested to see whether their ears were of
equal value—a matter of great importance in anti-aircraft work.

A Temporal Bone from a Case of Tuberculous Lateral Sinus
Thrombosis and Extra-cerebellar Abscess.

By E. D. D. Davis, F.R.C.S.

A BAKMAN, aged 37, was admitted to the medical ward on February 9,1922,
with temperature 103° F. f respiration 36, pulse 116. Consolidation of whole
lower lobe of left lung. Eusty sputum pronounced, and repeated vomiting of
three days’ duration. Diagnosis: pneumonia. Temperature subsided by crisis
on seventh day and chest signs disappeared. Patient intelligent and not drowsy.
No history of a rigor, but complained of occipital headache. Sputum : No T.B.
found. Patient sent to convalescent home, but returned a few days later, on
March 23, complaining of headache and vomiting. Temperature 101*4° F.

March 31 : First examination of ear and nose. Suppuration of right middle
ear of long duration. Granulation tissue polyp occupying posterior superior
wall. Neither mastoid tenderness nor oedema. Hearing : Voice, 2 ft.; bone
conduction normal. Slight nystagmus on looking to right increased by irriga¬
tion with hot lotion. Pupils equal and reacting. Optic discs : Outline blurred ;
frontal headache; patient drowsy and slow, with occasional vomiting. Stiff¬
ness of neck. Deep reflexes increased. No paralysis. Mastoid suppuration,
with possible posterior fossa abscess, diagnosed. Operation strongly advised,
but refused. Cerebro-spinal fluid: Increase in cells 61 per cubic millimetre,
chiefly lymphocytes. Albumin: 0*2 per cent, excess of globulin. Wassermann
reaction negative.

Patient became unconscious and died suddenly on April 24.

Post-mortem .—Cortex and its meninges normal. An abscess containing
about 2 drachms of pus was found on the surface of the right cerebellar
hemisphere, forming a slight cavity within the hemisphere and surrounding
the right lateral sinus. The dura, over an area corresponding to a five-shilling
piece extending from the tentorium to the foramen magnum, was covered by
pale granulation tissue and a number of small white tubercles could be seen
on the inner surface of the dura. The temporal bone was extensively necrosed
in front of the lateral sinus groove, and a sinus led outwards into an abscess
in the mastoid process. The lateral sinus was replaced by granulation tissue
and showed old thrombosis. The cerebellum was otherwise normal. No
tubercles were seen in the sylvian fissures or on the cortex. Petrous bone:
Chronic suppuration of right middle ear with polyp on posterior superior wall.
Mastoid full of pale granulation tissue and pus. A large sinus, in lateral sinus
groove, extending into the abscess in the posterior fossa. The outer mastoid
plate of bone was perforated in the suprameatal triangle, but there was no
subperiosteal abscess. The mastoid antrum was full of granulation tissue but

6 Davis: Temporal Bone; Dundas-Grant: Suppuration

most of the bone disease surrounded the lateral sinus. Sections of the granu¬
lation tissue and dura were stated to be tuberculous. Lungs: Broncho¬
pneumonia, old tuberculous foci and pleuritic adhesions. Nothing to suggest
infarction such as is seen in lateral sinus thrombosis.

Mr. Sydney Scott said that he believed cases like Mr. Davis described must be
rare. Hitherto he knew of only one recorded case of tuberculosis of the lateral sinus.
This was published in the Proceedings of the Royal Society of Medicine , 1916, ix
(Section of Otology), p. 84. He had shown the histological preparations demon¬
strating tuberculosis in the lateral sinus, the contents of which were removed when
the child was about 5 years of age. She was now 18 years old, and her father, a well-
known medical man, said she was in perfect health.

Case of Acute Suppuration in one Ear subjected to Early
Operation on Account of Complete Deafness of opposite Ear.

By Sir James Dundas-Grant, K.B.E., M.D.

C., A MIDDLE-AGED man, with complete deafness in the left ear, radical
mastoid operation and precedent facial paralysis, developed acute suppuration
in his right middle ear, and for the moment was practically quite deaf. In
view of the serious possibility of permanent total deafness if by mischance the
right ear failed to recover, I considered it advisable to perform Schwartze's
operation a little more than a week after the onset, in spite of the absence of
“mastoid” signs, in order to leave nothing to chance. The wound was
closed, excepting a small opening at the lower part through which a strip of the
gauze plugging passed. When this was removed a small drainage tube was
inserted. Very rapid subsidence of the discharge, and healing of the perforation
with restoration of hearing followed.

I would suggest that complete deafness of the opposite ear is an indication
for expedition in performing the simple mastoid operation, though, in general,
a contra-indication for the radical operation.

DISCUSSION.

Dr. William Hill said this case raised a very important point, namely, whether
middle-ear suppuration could not have its course shortened by operation. He had
never regretted operating on such cases, though he had had occasion to regret having
put off operation. The Schwartze method was an operation there was no need to
hesitate about doing; it was a simple and easy procedure. A year ago he had had
a case in which the whole discharge ceased three days after Schwartze’s operation
had been done. At the same time he slit up the roof of the meatus, and there was no
further suppuration, neither was there any subsequent swelling. Mr. Heath advised
operating in these cases, and he called his particular operation a conservative one.
His (Dr. Hill’s) view, however, was that it was far from being conservative, for in many
of the cases dealt with by Mr. Heath it w r as an unnecessarily destructive proceeding.
There were no complications following Schwartze’s operation, and it was well worth
while to consider whether doing a Schwartze might not prevent the development of
more serious symptoms. Possibly the operation had been too much neglected.

Mr. H. J. Banks-Davis said that after a Schwartze operation there was the
possibility of the post-aural mastoid wound not closing, with a resulting visible fistula.
This could never occur if the post-aural wound was closed and meatal drainage was
employed as in the u Heath operation,” where any continuance of the aural discharge
could be more easily dealt with by the patient than if the discharge exuded from behind

Section of Otology

the ear. In women seeking employment this was often a serious disadvantage and a
great disfigurement; closing these fistulae was not always an easy matter.

Dr. Logan TURNER said that the present day tendency was to operate earlier than
formerly in acute middle-ear suppuration. He preferred the Schwartze operation to the
so-called Heath method as he believed that better drainage was obtained by Schwartze’s
operation.

Sir .Tames Dundas-Grant (in reply) said that, as this was the man’s only effective
ear, he worked for safety, rather than risk the possibility of total deafness. If the other
ear had been fairly good, he would have left it. In answer to Mr. Banks-Davis as to
the risk of a fistula persisting behind the ear, when that occurred, it was an indication
that the operation w'as all the more called for. If the disease settled down, the fistula
could be remedied by a plastic operation.

Case of Absolute Bilateral Deafness, with almost Complete
Loss of Vestibular Activity.

By Archer Ryland, F.R.C.S.Ed.

G. C., MALE, aged 30. First seen October 10, 1922. He joined the Army
in 1914, and deafness was not noted at that time. The deafness has come on
since that date and is due to congenital syphilis. The loss of hearing is com¬
plete, and, so far as investigated up to the present, the loss of vestibular
activity is also apparently complete except for a very slight response on the
part of the left labyrinth.

The following points may be noted :

(1) The voice is quite uncontrolled. The cochleo-palpebral, and Lombard
voice-raising tests are negative.

(2) Wassermann: Strong positive, -f -f.

(3) Eyes: Corneal nebulae; pupils unequal; left iritic margin irregular;
patches of retinitis at periphery ” have been reported by oculist.

(4) Teeth : Upper incisors Hutchinsonian in character.

DISCUSSION.

Sir James Dundas-Grant said he had seen slight degrees of improvement taking
place under increasing doses of arsenic combined with mercury—Donovan’s solution in
fact—even in congenital or hereditary specific disease, though there was not much
restoration of hearing. The general condition, in regard to giddiness, &c., had been
improved.

Mr. Archer Byland (in reply) said that the investigation of the case was at present
incomplete as he had not had an opportunity of fully recording the nature of the vesti¬
bular reactions. There was no mistaking the nature of the congenital defects, and the
Wassermann test was strongly positive. The point of interest of course was the manner
of invasion of the labyrinth and internal ear. The tympanic membranes on each side
were scarved, and this pointed to an obsolete suppurative middle-ear condition. This
was probably an illustration of a type of case, held by J. S. Fraser and others to be not
infrequent in occurrence, in which the original middle-ear infection was syphilitic
(though, later, probably polymicrobic), slowly invading the petrous bone and attacking the
labyrinthine capsule, giving rise to a chronic form of osteomyelitis which slowly invaded
the perilymph space of the labyrinth. There had been no history of sudden attack on
the labyrinth, but of a gradual progress to absolute deafness and loss of vestibular
function.

Jenkins: Tinnitus associated with Facial Spasm

Tinnitus associated with Facial Spasm.

By GL J. Jenkins, F.R.C.S.

Patient, a female, aged 53. Spasm of left facial nerve, one year and five
months. Tinnitus began with onset of the spasm. A single twitch of the
muscles was associated with a synchronous noise in the left ear. Patient
described the noise as a “ bang.” When twitches followed one another rapidly
the noise was like the “ popping of a motor car.” When twitches were very
rapid the noise became continuous and sometimes bell-like. There was pain in
the left ear at the onset of the disease, when the twitching was very bad.
Post-suppurative effects in the right ear. Tympanic membrane on left side:
opacities. A detailed examination is being made.

DISCUSSION.

Sir JAMES Dundas-Grant said he thought the murmur was perhaps a muscular
one caused by the contraction of the stapedius, associated with contraction of the facial
muscles. If the normal subject closed the ears and then shut the eyes tightly, a deep-
toned hum was perceptible. Mr. Jenkins’ patient said that the sound she was hearing
was the same as that which followed the energetic shutting of the eyes in the way
mentioned.

Mr. SYDNEY Scott said he had seen some similar cases at Queen Square, but was
unable to throw light on the pathology. He believed the subjective noise might be
caused by the repeated contractions of the stapedius, because in some cases the patient
felt momentarily giddy during the attacks of twitching of the face. This patient said
she was not giddy, but she was deaf in the opposite ear.

Mr. G. J. Jenkins (in reply) said he had shown this case because it seemed to be
one in which a specific cause for the tinnitus could be made out. There was a spasm
of the left seventh cranial nerve. The tinnitus might possibly be due to the sound
produced by the contraction of the facial muscles being conducted to the ear, or by a
movement of the pinna, but he thought it was due to the movement of the stapes
produced by the contraction of the stapedius muscle. As to whether the tinnitus was
due to the simple movement of the stapes or to a vibration set up in the tympanic
membrane and ossicles, it was difficult to say, but he thought it was more likely to be
due to movement of the stapes itself.

Section of ©toloap.

President—Mr. Hunter Tod, F.R.C.S.

Chairman—Sir Charles Ballance, K.C.M.G., C.B., M.V.O., M.S.

Some Cases of Otosclerosis with an Unusual Symptom
(Otosclerosis Paradoxica ). 1

By Albert A. Gray, M.D.

(ABSTRACT.)

Dr. Albert A. Gray read a paper giving the history of four cases of
otosclerosis in which the patients heard better during a severe cold or if, when
in a state of exhaustion, they had received some unusual stimulus.

Case I. —Patient, a woman aged 44, had begun to grow deaf at the age of
30; a year or two later she was troubled with noises in the ears and had
noticeable paracusis. Inflation with the catheter produced little or no improve¬
ment in either ear. When she had a cold, however, she could hear a conversa¬
tion carried on in an ordinary voice.

Case II. —Patient, a woman aged 41, had begun to grow' deaf at the age of
25. Paracusis willisii was present and there was definite otosclerosis. Every
year she had hay fever during which her hearing improved very much, declining
again as the fever subsided. In this case an ordinary cold in the head was not
accompanied by an equal improvement in hearing.

In the next two cases the improvement in hearing was only momentary;
in both these cases also the patients had otosclerosis.

Case III. —Patient, a woman. Tinnitus was present in a moderate
degree and there was paracusis willisii. The patient had suffered from
deafness for many years. One evening in an overheated room she opened a
window and stood in a cooling draught. Her hearing at once became so much
better that she heard the conversation going on in the room, though previously
she had heard practically nothing of it. The improvement lasted for two-
minutes and ended suddenly. It was the patient's only experience of the kind.

Case IV. —Patient, a woman aged 34, had fleeting tinnitus and paracusis
willisii was present in a striking degree. Both tympanic membranes were
normal. There was no family history of deafness. In this case deafness had
begun at the age of 22 and had been gradual in onset. The patient was a total

1 This paper is published in full in the Journal of Laryngology and Otology , March, 1923.

[November 17, 1922.

Mh- Ot 1

10 Gray: Otosclerosis with an Unusual Symptom

abstainer. After a drive in a motor-car during very warm weather she bad
become on one occasion exhausted and somewhat faint. She was persuaded to
take a dessertspoonful of brandy and her hearing immediately improved so
much that she could hear conversation carried on in an ordinary tone. The
improvement in this case also lasted only two or three minutes. Subsequent
taking of brandy, when the patient was not exhausted, did not produce any
improvement in hearing.

Dr. Gray said that otologists were not yet agreed as to the causation of
paracusis. It had been attributed to movements of the stapes and other
ossicles which enabled sounds of smaller vibration to reach the labyrinth, but
he (Dr. Gray) felt sceptical about this explanation, because in the cases he had
described the improvement had occurred when there had not been anything to
cause movements of the stapes and other ossicles. In the last two cases there
was an unusual stimulus, during a period of exhaustion—in one case, the cool
draught, in the other, the alcohol—which might have caused a sudden change
in the circulation. Dr. Gray named the condition “ otosclerosis paradoxical’

DISCUSSION.

Mr. J. F. O’Malley said that apparently Dr. Gray was not convinced as to the
accuracy of the generally accepted explanation of paracusis ; he (Mr. O’Malley) with
many more, had accepted it as true. It was difficult to find evidence that the stapes
was the responsible factor. The idea had occurred to him that the condition of the
perilymph might be a factor of importance, and he would like to hear whether Dr. Gray
considered that an alteration in the perilymph—especially in its quantity—was a
probable factor in the causation of paracusis. He had read, in an old book, reports
of examinations in which the labyrinths were devoid of fluid after death. There were
certain peculiarities associated with some of these cases which would lead to the belief
that there were changes in the labyrinthine fluids, and these changes must have a
considerable influence on the hearing.

Mr. Richard Lake said he certainly remembered one case in which the patient
heard much better during a cold, but he did not remember particulars of it. Possibly
the improvement might be of toxic origin, i.e., the stimulus to better healing might
be a toxin evolved during the catarrh. He had still under cognizance a deaf mute,
who could hear very slightly. A few years ago she had post-influenzal pneumonia, and
during the time she was practically in extremis in that illness, she heard better than
she had ever done before. The suggestion he made to her father at that time was,
that the improvement must have been due to the toxaemia from which she was suffering.
Children in a toxaemic condition, if they were not really stupid, had a very acute
cerebration during the illness. Dr. Gray’s patients might have had a toxaemia at the
time, though of mild form, and the stimulus might have acted not only on the nerv e
endings, but also on the central nervous system.

Mr. M. Vlasto said he thought the most scientific attitude w T ould be to accept the
facts communicated to Dr. Gray by his patients as correct. It would be serviceable if
members searched their memories and records for cases of otosclerosis in which the
deafness was improved under varying conditions. He asked if Dr. Gray had heard of
a case of otitis media sicca in which the hearing was improved during an attack
of coryza.

Sir JAMES Dundas-Grant said he recalled, in this connexion, the observations
made in Paris by Sir Robert Woods, namely, that during or after acute inflammation
the deafness in otosclerosis sometimes seemed rather less marked. Sir Robert Woods
had devised a method of injecting some irritant fluid through the tympanic membrane.
One case had been described in which the result seemed to have been promising.

Section of Otology

This indicated that the increased vascularity, even if only temporary, was the agent in
the momentary improvement. Patients had told him (Sir James Dundas-Grant) that
they heard better when they had a cold ; he had not paid sufficient attention to it, but
he would attach significance to such statements in future. Dr. Gray’s patients seemed
to have heard a conversational voice much better than they heard a whisper; but in
otosclerosis the patient not infrequently heard the whisper better, a fact that was
becoming recognized as one of the signs of otosclerosis. Perhaps he, himself, had used
a more penetrating whisper than Dr. Gray did in the test, giving the high-pitched
harmonics of the voice more prominence. With regard to paracusis, he asked whether
Mr. Cleminson had pursued the observations with the apparatus demonstrated at the
last meeting by Mr. Somerville Hastings, which seemed to prove the reality of
paracusis more certainly than anything he had encountered. Experiments made
in other ways had been open to doubt as to whether the patient actually had better
hearing, or whether there was unconscious raising of the speaker’s voice caused by the
noise which was heard by the speaker.

Mr. F. J. Cleminson said Mr. Somerville Hastings had scarcely been available since
the last meeting. He (Mr. Cleminson) saw a patient with otosclerosis, and,
remembering the beneficial effect of nitrate of amyl, he tested her with the watch,
and found she could hear with the right ear 3 in., with the left, 2 in. Then he
applied a Siegle’s speculum and produced a negative pressure until he could see
not only the vessels along the handle of the malleus, but also the radial vessels from
the malleus handle to the periphery of the drum. At this stage he found she could
hear the watch with the right ear, 10 in., and with the left, 3 in. He continued to
test her every minute afterwards, and found the duration of the improvement was
three to five minutes, after which she relapsed into the state in which she was
before the experiment began. That seemed to support the view* that the improvement
was due to a vascular change.

Mr. W. M. Mollison said he did not doubt that an increased peripheral vascularity
had an effect on the hearing. Women often noticed that deafness became worse after
the birth of each child, but just before parturition they heard better; at such times the
circulation was enormously enhanced, and was consequently more vigorous in the ear.
The fact that patients heard better when they had a cold might also be due to enhanced
peripheral circulation. Otosclerotics also improved when given pilocarpine.

Mr. G. J. JENKINS said the problem introduced by Dr. Gray was a very far-reaching
one, too large to deal with adequately in a few minutes. At the International Congress
in 1913 he (Mr. Jenkins) tried to show that probably some of the symptoms of
otosclerosis were due to changes in the fluid, and he used a hot-water douche for the
ears of patients with otosclerosis, beginning with water of body temperature, and going
up to quite a high temperature. For a short time after this hot douche patients heard
better. The effect of chloroform on the hearing of patients suffering from otosclerosis
should be remembered, as individuals with normal hearing had increased acuity of
hearing with certain doses of chloroform. He knew' of a doctor suffering from
otosclerosis whose habit was to take chloroform before starting his round, although
the effect only lasted about an hour at a time. Paracusis patients also heard better
during yawning, possibly owing to the effect on the labyrinthine fluid.

Mr. H. Tilley reminded members that the stimulation produced by Sir Robert
Wood*} wets induced by the injection of an iodine preparation into the middle ear.

Dr. Gray (in reply) agreed that, in its broad application, the subject was a large one ;
hut the purpose of the present paper was to secure interest in this particular phase : the
better hearing in otosclerosis when there was present an abnormal condition, such as a
cold. It had always been the custom to think of otosclerosis as being due specially to
fixation of the stapes, and he regarded that as a fundamental error, as the fixation of
the stapes was only one manifestation of the disease. The change in the bony capsule
of the labyrinth was an atrophic change. He believed otosclerosis to be a disease of the
whole organ of hearing, from the auricle to the cortex. In answer to Mr. O’Malley as

Layton : “ The Disease of not Listening ”

to the perilymph, he (Dr. Gray) did not know whether there was more or less perilymph
than normal in otosclerosis. With regard to Mr. Lake’s point concerning toxaemia,
that was a very interesting matter, because it was true that many toxins did produce
an effect on the vasomotor system ; the shivering and heat at the beginning of scarlet
fever or measles was due to the effect of the toxin on the vasomotor system. The same
explanation might be true in the case of pilocarpine, as that drug also produced a
marked effect on the vasomotor system. He had never known this condition occur in
chronic otitis media, it occurred only in otosclerosis. He remembered Sir Robert
Woods’ contribution in Paris : he injected iodine into the middle ear in chronic otitis
media. Otosclerosis might have been present too. He (Dr. Gray) thought the effect
was more likely to be due to stimulation of the mucous membrane of the tympanum,
and there was probably a reflex dilatation of the blood-vessels in the labyrinth. With
regard to the suction of the tympanic membrane, mentioned by Mr. Cleminson, in that
case the effect might have been due to dilatation of the blood-vessels in the labyrinth ;
but when the stapes was fixed, it was difficult to see how that could occur. Unless the
stapes were movable, any suction on the tympanic membrane would be compensated
for by air coming up through the Eustachian tube. If, however, there was some
obstruction in the Eustachian tube it might occur. Another explanation was that
there might be stimulation of the nerve endings in the tympanic membrane, with
coincident dilatation of blood-vessels in the labyrinth. The same explanation would
apply to Mr. Jenkins’ warm douche. The important point was, that one could not
look upon the deafness of otosclerosis as being due only to the mechanical fixation of
the stapes. A fixed stapes was a constant factor, and if the deafness was due to that,
nothing in the way of dilatation of the vessels would produce any effect. It was much
more likely that in these cases there was a reflex dilatation of the blood-vessels when
nasal catarrh was present. He (Dr. Gray) thought the statements made by the patients
in these cases were obviously true ; in the case he described first in the series he knew
it was true ; it happened in a distant relative, and he had been present when she had
a cold: there was no doubt about the striking difference in the hearing during
the cold.

“ The Disease of not Listening, the Malady of not Marking .” 1

(Henry IV, Pt. ii, Act 1 , Scene 2.)

By T. B. Layton, D.S.O., M.S.

(ABSTRACT.)

~ Mr. Layton said that between the malingerer and the case of functional
deafness there must be at least two other stages. One was the stage of “ the
subconscious malingerer ” ; this was the person who did not intentionally try
to cheat but who gave the examiner no assistance in his examination ; the other
was that of the person who had lost all interest in his surroundings and seemed
never to take any notice of anything until it was forced upon him. The
difference between these types might be explained by a study of the subject of
attention. Ribot’s classification of spontaneous or natural attention and
voluntary or artificial attention, was a useful standpoint from which to study
the cases. Mr. Layton believed that in functional deafness auditory attention,
both spontaneous and voluntary, was entirely in abeyance; that in the people
who took no notice of anything (as exemplified by cases of severe shell-shock)
all forms of voluntary attention were largely in abeyance, and of spontaneous

i This paper is published in full in the Journal of Laryngology and Otology, March, 1923.

Section of Otology

attention partly so; that in the subconscious malingerer the voluntary attention
was withdrawn but was not in opposition to the examiner, while the spontaneous
attention remained normal, whereas in the true malingerer the voluntary atten¬
tion was very much in action but was in opposition to the examiner instead of
being in sympathy with him.

Mr. Layton said that the diagnosis of the malingerer should be made in
three stages : that of observing unusual behaviour ; that in which the examiner
determined that the unusual behaviour was due to malingering; and that in
which the examiner proved the examinee to be cheating intentionally. He
thought that in civil practice some lessons might be learned from the various
types of cases seen during work for the Ministry of Pensions.

First: That in the cases of severe deafness when nothing could be done for
the deafness, much could be done for the patient if he was beginning to allow
his attention to fail. Secondly : In considering the deafness of school children
and realizing the extreme difficulty of testing hearing in children, it should be
realized that it might be not that the child was deaf but that the school teacher
was unable to hold his attention ; and thirdly, that in some children it might
be reasonable to advise special private tuition if it were proved that their
hearing was normal but that they were not properly developing their powers of
voluntary attention.

DISCUSSION.

Dr. A. H. Uriel said lie thought that in examining pensioners it was important to
see whether the appearances in the drum corresponded with the results of the
functional tests. If the appearances in the drum corresponded to the functional
tests, it tended to show that the responses of the patient were correct.

Mr. M. Vlasto remarked on the omission from Mr. Layton’s paper of a reference to
day-dreaming. This occupied a place of much importance in the child’s life, and
during its sway the young person was oblivious of all that was going on around. In
the adenoid child one of the distant receptors—audition—was partly in abeyance, and
a vicious circle was thus set up.

Mr. G. J. JENKINS said that all individuals were non-listeners. Non-listening was
a physiological process, and the ltinne and Weber tests depended upon this fact to
some extent. A girl had come to King’s College Hospital the previous day with
complete deafness in one ear. She had to sleep in a house in which there were many
rats, and next morning she was unable to hear at all with one ear. On Weber’s test
the sound went to the good ear; and in that ear the hearing was normal. There was
no sign of disease, and the caloric test showed that she had normal vestibular reaction
of the labyrinth of the deaf ear. He (Mr. Jenkins) asked her to come into the hospital
and have it put right next day, and this led to hesitation, and questions as to whether
she would be operated on, or hurt. There was something more than pure hysteria in
the case, which was to be further investigated. But the point on which he
(Mr. Jenkins) insisted was that we were all non - listeners; ail were “ not listening” at
every' moment of the day, and it was an exaggeration or aberration of this normal
physiological state which in many cases was responsible for functional deafness.

Sir James Dundas-Grant said he had frequently noticed in dealing with deaf
soldiers, that sometimes there was a very high degree of deafness accompanying a
slight, removable condition, and when that condition was removed, the improvement in
hearing was out of proportion to that which one was accustomed to see in civil practice.
In some cases one successful Eustachian catheterization altered the aspect of the patient
altogether ; he brightened up at once, and took a totally different view of life.
Similarly tightening up a relaxed membrane by means of collodion would have the same

Layton: “ The Disease of not Listening ”

effect, as also the removal of nasal obstruction. Obviously, therefore, the deafness in
such cases was not solely due to organic changes, the psychical factor playing a large part.
With regard to caloric tests, he agreed with Dr. Hurst, that if there was absence of
vestibular reflex, the deafness should be put down as of organic origin. The converse,
however, was not always true: although the vestibular reflex might be present, the
deafness might be organic. He thought there was a greater degree of vulnerability of
the acoustic part of the nerve than of the vestibular.

Dr. A. A. Gray said he believed that FalstafFs wrords were : “ This apoplexy, I take
it, is a kind of deafness,” which expressed the idea that there was an association between
apoplexy and deafness.

The following Cases and Specimens were shown :—

(1) Case of complete Nerve-dfeafness due to Syphilis of Internal Ears.

By Sir James Dundas-Grant, K.B.E., M.D.

(2) Case of Otitis Media with Facial Palsy, following Scarlet Fever.

By F. J. Cleminson, M.Ch.

(3) Specimen: Malleus and Incus removed from the Left Ear of a Child

with Chronic Otitis Media. By F. J. CLEMINSON, M.Ch.

(4) Specimen: A Wart Horn removed from the Right Ear of a Man

aged 63. By F. J. Cleminson, M.Ch.

The cases will be published with the report of the next meeting (January 19)
to which the discussion was deferred.

Section of ©tologp.

Acting President—Sir Charles Ballance, K.C.M.G., C.B., M.V.O.,

M.S.

Labyrinthitis as a Complication of Middle-ear
Suppuration.

By A. Logan Turner, M.D., and J. S. Fraser, M.B.

(ABSTRACT.)

The Report, which will be published in extenso in the Journal of Laryngology
and Otology , was based upon the authors’ observations in the Ear and Throat
Department of the Royal Infirmary, Edinburgh, and covered a period of fifteen
years, 1907-21. In 10,653 suppurating ears, an affection of the labyrinth was
diagnosed in 124, i.e., in 1*1 per cent. The types of labyrinthitis met with
were: Circumscribed labyrinthitis, 27 ; acute serous labyrinthitis, 3; acute
purulent (manifest) labyrinthitis, 23 ; chronic purulent (latent) labyrinthitis, 54 ;
and the healed functionless labyrinth, 17. Intracranial complications occurred
in 45 of the cases with inner ear disease : of these, 24 were regarded as directly
traceable to the labyrinthitis, viz., 20 cases of lepto-meningitis and 4 of
cerebellar abscess. Of 1,720 mastoid operations performed during the period
under review, post-operative labyrinthitis supervened in 6, i.e., 0*3 per cent.

A number of lantern slides showing the pathological changes met with
in the labyrinth in the dffferent types of labyrinthitis were shown by
Mr. J. S. Fraser.

DISCUSSION.

Dr. Albert Gray expressed his high appreciation of the beauty of Mr. Fraser’s
prepared specimens, which surpassed that of any previous collection exhibited by
Mr. Fraser before. He did not quite agree with one remark made by Mr. Fraser when
he said that the change in the bone in one case was like that of otosclerosis. Certainly
it was like that condition from the fact that the bone was less dense, but it had none of
the sharp line of demarcation that typical cases of otosclerosis showed, and the bone
did not stain so deeply as in typical otosclerosis.

Mr. Sydney Scott commented on the excellent organization which existed at
Edinburgh for getting cases worked out and all the details recorded and classified.
He said it had been interesting to see the various stages resulting from labyrinthitis,
from the localized infection with a small erosion, to those in which there were granula¬
tions, and finally where the labyrinth had been destroyed and in the end obliterated
by the formation of new bone. He had seen only one case in which the whole labyrinth
was replaced by bone tissue, but in that case no history could be obtained ; it was an
ordinary dissecting room specimen, the patient having come from a Poor-law infirmary.
He took it that such a condition was the final result of infection. He was not
favourably inclined to the use of the word “serous” as applied to labyrinthitis. He
presumed the term was applied to cases in which the clinical manifestations were mild or
perhaps corresponded to a localized infection. There was a type of case he had never
seen recorded in which an ordinary radical operation on a patient was performed for,
say. cholesteatoma or granulations in the middle ear without signs of internal ear
disease. No signs of erosion of the labyrinth would be found at the operation, and no
untoward signs would arise until three or four weeks afterwards, when, on a spot
on the inner wall of the cavity being touched, violent vertigo, forced movements of the
head and limbs and nystagmus occurred, i.e., the fistula symptom had appeared about
the fourth week after the radical operation. The semicircular canal had not been

Ar—O t 1 [January 19, 1923.

Turner and Fraser—Dundas-Grant

opened at the operation; probably the outer bony wall of the external canal was very
thin and the granulations formed during reparation from the Haversian canals caused
rarefaction of bone which, yielding to direct pressure with the probe, transmitted
changes of pressure to the labyrinthine fluid. He had seen this in five cases. He had
not been disposed to open the labyrinth because he had seen that sign, and after a
variable period, sometimes as long as three months, the fistula sign had disappeared
in all these cases. He had been interested to note the number of cases at Edinburgh,
where meningitis due to labyrinthitis had been treated by the operation of trans-
labyrinthine drainage. Probably Dr. Turner’s and Mr. Fraser’s experience was the
same as that of other members, that these cases were generally received too late.
It could not be too well known that this form of meningitis could only be dealt
with hopefully if the condition was recognized early, especially by general practitioners
and physicians, who were often consulted first.

Mr. G. J. Jenkins said that the communication made was excellent. All recognized
the advantage of the Edinburgh methods in being able to follow out the cases, and the
organization of the clerical part of it which was practised. He agreed with what
Mr. Scott said about the terms 44 serous ” and 44 exudative ”; at the International
Congress he (Mr. Jenkins) made a point of that in dealing with meningitis. A more
accurate term should be employed. These were inflammations at different stages, and
the matter could be left at that. With regard to cases with perforation of the external
semicircular canal coming late, at the present time he had two cases under observation.
One of these patients was now almost well, and the other was on the road to recovery.

Dr. LOGAN Turner (in reply) said that team work was what was needed everywhere,
and he was always glad to feel that they in the North had been able to do something in
that way. He had often wished there was more of it, so that the statistics of one clinic
could be combined with those of others, and really valuable material thus obtained.
With regard to the use of the word 44 serous,” they had limited the application of it to
that type of labyrinth affection in which there was still some function. Those cases
in which no labyrinth response was obtained on testing they regarded as purulent.

Mr. J. S. Fraser (in reply) said that he did not think this w-as the occasion for
discussing with Dr. Gray the question of otosclerosis; they had exchanged views many
times before. He (Mr. Fraser) contended that it was an inflammatory disease, Dr. Gray
said it was not. He (Mr. Fraser) did contend that the changes shown that day, in the
labyrinth capsule, were an early stage of otosclerosis. With regard to organization,
they in Edinburgh owed much to the secretaries who worked with the surgeons and
physicians at the ear and throat department. On arriving in the morning they found
that all the case-histories had been taken very well. (Dr. Turner’s secretary had
been working at the department for twenty years, and his own about eight years.)
Therefore when he (Mr. Fraser) arrived, all he had to do was to examine the nose, ear
or throat, and dictate to his secretary the conditions found there. In the same way
after an operation the findings were dictated and entered in the case sheet. Both
Dr. Turner and he were greatly indebted to the work of Mr. West and Mr. Sydney Scott
on translabyrinthine drainage. Several of their patients would have died if this
procedure had not been carried out.

Case of Complete Nerve-deafness due to Syphilis of Internal
Ears ; Caloric and Rotation Tests Negative, Galvanic Positive.

By Sir James Dundas-Grant, K.B.E., M.D.

[Shown at the last meeting, December 15, 1922.]

Patient, female, aged 21. Deaf eleven years. Stigmata pronounced.
Tests indicate lesion of labyrinth without involvement of nerve-trunk.

Section of Otology

DISCUSSION. (January 19, 1928.)

Sir James Dundas-Grant said the indication was that the nerve endings in the
labyrinth were destroyed by the disease, but the nerve itself was sound, and responded
to galvanism.

Mr. J. F. O’MALLEY said that the case was very interesting considered from the
point of view of the development of the vestibular and cochlear nerves, because they
developed in the same way as a posterior root nerve, so when there was disease
confined to the labyrinth, the cochlear ganglion was likely to suffer total extinction,
w hilst the vestibular ganglion, which lay in the internal auditory meatus, might escape,
although its terminations in the labyrinth were destroyed.

Case of Otitis Media with Facial Palsy, following Scarlet
Fever; Specimens (Malleus and Incus) shown.

By F. J. Cleminson, F.R.C.S.

[Shown at the last meeting, December 15, 1922.]

S. A., AGED 2 years and 10 months, was brought up to the Evelina Hospital
on September 8, 1922, with a discharge from both ears. There was pus in
the left meatus and an incomplete right facial palsy. The history given by the
mother was as follows : Up to April 25, of this year, the child was well and
had normal hearing so far as the parents could say. On that day she was
admitted to an isolation hospital for scarlet fever. While there she developed
4 ‘ measles and diphtheria of the nose.” She was discharged one week before her
first visit to the Evelina Hospital. The facial weakness was said to be improving.

The patient was sent to have her right ear syringed by a nurse, who brought
hack a perfectly macerated malleus and incus, without any sign of caries.
The nurse had seen the ossicles evacuated with the lotion, and had rescued
them from it.

The patient is apparently totally deaf, even the loudest sounds failing to
attract her attention. While under observation the condition of the lower
face (especially that of the muscles which retract the angle of the mouth) has
improved very noticeably.

[The ossicles were shown as a separate exhibit.]

DISCUSSION. (January 19, 1928.)

Mr. Cleminson said he showed the case because it was known that rapid destruction
of bone might take place in cases of scarlet fever, but he had never before seen a case
in which the ligaments dissolved without affecting the integrity of the bones. As
already stated, the child was aged 2 years 2 months when admitted to the Fever
Hospital, and she could then hear and talk, but was now a deaf-mute, and had not said
a single word during her stay in the Evelina Hospital. After she had been shown at
the November meeting she was found to be carrying the infection of scarlet fever,
and the opposite ear, being in a state of chronic purulent inflammation, had therefore
been subjected to a radical mastoid operation, and had become dry. Since then there
had been no further suspicion of “ carrying.” The facial palsy was still showing a
slow' improvement.

Mr. J. S. FRASER asked what w f as the opinion of members as to paralysis of the
face being an indication for operation in acute otitis media. In books one always
read that it constituted a reason for the performance of a Schwartze operation. Did
members uphold that teaching, or did they believe that if there w r as no other
indication for operation, such as pain, temperature or swelling, the mastoid should
be left unopened, it being trusted that the facial paralysis would clear up ?

Cleminson: Otitis Media; Dundas-Grant: Vertigo

Mr. H. J. Banks-DAVIS said he did not think the facial paralysis did clear up
easily in those cases. He was impressed by two cases in particular. One was that
of a nurse, who had had acute otitis media, with nothing in the way of symptoms
except a slight pain in the ear. Her face was paralysed, the paralysis having come on
within three days. He thought it better to do nothing, but the facial paralysis became
rapidly worse, and reaction of degeneration was distinctly present. He then opened
the mastoid antrum, and the condition cleared up, but only very slowly. - Facial
paralysis was liable to continue for a long time, and he thought the mastoid should be
opened, as there might be something pressing on the nerve. When he saw aural cases
with facial paralysis he admitted them as urgent cases, and opened the mastoid
without delay. The other woman to whom he referred had had her facial paralysis
two years before recovery under electrical treatment; yet both of these cases were
apparently identical.

Mr. W. M. MOLLISON said he remembered two particular cases of acute otitis
media with facial paralysis, in which free incision of the membrane cured the paralysis
in a few days : one, a child, in three days, one, an adult, in ten days. He did not
regard facial paralysis in otitis media as an indication to open the mastoid. If the
acute otitis media had been present some days and the paralysis then developed, the
case would be different. In the two cases he had mentioned the facial paralysis
developed almost simultaneously with the otitis. He believed increased pressure of
fluid in the tympanum was communicated to the nerve through one of the dehiscences
in the Fallopian canal.

Mr. SYDNEY SCOTT (in reply to Mr. Fraser’s question) said that, in principle, he
would be more inclined to open the mastoid if facial paralysis set in, in association with
otitis media. The class of case being discussed was that in which acute otitis media
developed, and the patient sooner or later had facial paralysis. He regarded that as an
indication for extra free drainage.

Dr. Logan Turner said his experience agreed with that of Mr. Mollison.
Facial paralysis would clear up without operation. Two cases were recorded in the
Journal of Laryngology last year in which the paralysis disappeared without
interference.

Mr. G. J. Jenkins : Is not the one in a hundred the important one, rather than the
majority ?

Sir James Dundas-Grant doubted that in every case of Bell’s paralysis the con¬
dition was due to inflammation in the middle ear. In Mr. Mollison’s case the
tympanum was not yet open, but he presumed there were all the other signs of acute
suppuration of the middle ear: bulging and redness, and in the presence of these
he agreed with Mr. Mollison’s line of action, namely, to open the tympanum
freely, and if the paralysis did not then speedily subside, to do a Schwartze operation.

Mr. Cleminson (in reply) read extracts from the notes taken at the fever hospital,
which he did not possess when the child was shown ; these showed that the facial
palsy was first noticed six weeks after the onset of the otorrhoea.

Case of Vertigo, with Fixation of the Ossicles, cured by

Ossiculectomy.

By Sir James Dundas-Grant, K.B.E., M.D.

PATIENT, a male, aged 24, suffered from frequent attacks of giddiness so
severe as to make him to fall down. He had chronic suppuration in the left
ear, which was satisfactorily dealt with by a modified mastoid operation, but
the vertiginous attacks persisted and it was found that they were excited by
the slightest pressure on the right tragus. The right malleus was found to be

Section of Otology

absolutely tied down to the promontory by cicatricial adhesions. After the
removal of the ossicles the vertigo disappeared almost entirely and it could no
longer be induced by pressure on the tragus.

The explanation of the relief is probably that the malleus fixation rendered
the incus and stapes immobile and that the pressure of air when the tragus
was pushed in acted upon the membrane of the round window with an
abnormal degree of disturbance of the internal ear owing to the loss of the
safety-valve action of the stapes in the fenestra ovalis.

The hearing power for the whisper on the right side has improved from
5 ft. (before) up to 20 ft. (after the operation).

Parotid Fistula following Mastoid Operations.

By Norman Patterson, F.R.C.S.

Patient, a girl, aged 12. History of right otorrhcea on and off since
infancy. Seen at London Hospital, September 19,1921. History of severe pain.
Purulent discharge present, right ear; redness and bulging posterior meatal
wall; posterior perforation; tenderness over mastoid. Temperature 100*5° F.,
pulse 120, respiration 24. Operation same day. Complete mastoidectomy, bone
cellular, cholesteatoma in middle ear, lateral sinus exposed and appeared
healthy. September 21 : Temperature 103° F., pulse 120. Wound opened up.
Decomposing blood clot and sloughs removed. Lateral sinus examined but
looked healthy. On November 26 the temperature, which had fallen to normal,
rose to 102° F. Anaesthetic given. More sloughs removed. The lateral sinus
was found to contain a parietal clot. The operation was completed by ligaturing
the internal jugular vein. Examination of cerebro-spinal fluid obtained by
lumbar puncture negative. Blood culture grew a haemolytic streptococcus.
For a week temperature swinging, up to 104° F. After this temperature
slowly came down to normal, and patient was sent to convalescent home on
November 28.

On February 1, 1922, swelling noticed in operation scar. This swelling
burst; the discharge was at first blood-stained, then clear. The discharge
persisted. It was not at this time realized that it came from the parotid.

May 22, 1922: Wound opened up and curetted. It was discovered that
the sinus did not lead into the mastoid cavity.

Present condition : Middle ear healed. Depressed scar over mastoid with
very small opening from which saliva persistently drains. The flow is
increased by getting the patient to chew something, such as a sweet. The
fluid has been examined by Dr. Panton, who reports that diastase is present in
large amount.

The patient will shortly be readmitted, and it is proposed to cauterize the
fistula.

DISCUSSION.

Mr. H. J. Banks-Davis said that four years ago 1 he showed a man, aged 50, with
parotid fistula, who came to the casualty department with “earache,” and developed
a small abscess at the tip of the mastoid. It was opened by the house surgeon and a
clear salivary discharge developed from the minute scar in the neck. Healing was
ver >’ slow. He tried cauterizing it, and eventually it was cured by ionization.
Cauterizing might make the sinus larger, and he would suggest ionization with a metal
probe in the sinus first.

1 Proceedings , 1917-18, ,\i (Sect. Otol.), p. 55.

Scott—Lowry—Dundas-Grrant

Mr. Norman Patterson (in reply) said that he brought the case as a curiosity,
and in order to elicit suggestions as to treatment. He had intended to cauterize the
fistula, but he delayed that procedure until he had shown the case to the Section. If
cauterization did not prove successful, he would try ionization, and report the result.

Ossification of Incus to Tegmen.

By Sydney Scott, M.S.

This specimen is from a case of radical mastoid operation for chole¬
steatoma ; bony ankylosis of the body of the incus to the tegmen was
discovered.

In the case of cholesteatoma there is usually no trace of the incus. In the
specimen shown the incus was perfect except where the body and posterior
limb were fixed to the tegmen by a mass of new bone. The patient was very
deaf, as one would expect with this bony ankylosis.

Case of Acquired Atresia of the Auditory Meatus.

By E. Lowry, M.B.

Mrs. C., aged 32 , has been complaining of deafness in the left ear for the
last two years.

History : Three and a half years ago she had a lower left molar extracted,
after which she first noticed discharge from the left ear which lasted for four
weeks. There is no history of any previous illness.

Present condition : Right ear normal. Left ear completely deaf as regards
air conduction. Rinne negative. The meatus is completely closed by a fibrous
membrane close to the surface. This case is shown in order to obtain advice
as to operative treatment.

Case of Vertigo (simulating “ M6ni£re’s Disease ”) with
Anomalous Nystagmus Reactions,

By Sir James Dundas-Grant, K.B.E., M.B.

K. A., FEMALE, aged 35, first seen by the exhibitor in November, 1922,
complained of frequent attacks of vertigo with vomiting, the first attack having
come on suddenly about a year previously. There was deafness of the right
ear, the bone conduction was diminished and the hearing for Galton’s whistle
did not extend above the mark 3’4. There was spontaneous nystagmus which,
instead of being to the side opposite to the apparent lesion, was towards the
same side and there was marked falling to the opposite side. A simple laby¬
rinthine lesion would not produce this. The caloric (cold air) and rotation
tests produced normal nystagmus, but to a lesser degree on the right than
the left side; there was complete absence of past-pointing to either side and
the falling was invariably towards the sound side, whichever ear was acted
upon. Wassermann reaction negative. Perhaps a neurological examination
will suggest a lesion in the superior cerebellar peduncle. The result will be
reported at the next meeting.

Section of ©tolofls.

Chairman—Sir Charles Ballance, K.C.M.G., M.S. (Vice-President

of the Section).

Otosclerosis and Osteitis Deformans: A Pathological and

Clinical Comparison.

By G. J. Jenkins, F.K.C.S.

(ABSTRACT.) 1

The subject may be considered under the following headings:—

(1) A comparison of the pathological changes occurring in bone in osteitis
deformans and otosclerosis respectively.

(2) A comparison of the clinical aspects of osteitis deformans with those of
otosclerosis.

(3) Conclusions.

The microscopic sections demonstrated are selected from serial sections of
the temporal bones of three subjects, two from cases of osteitis deformans and
one from a case of otosclerosis.

The first series of sections is from the temporal bone of a female, aged 84.
(Cephalic osteitis deformans.)

The second series is from the temporal bone of a male, aged 61. (Osteitis
deformans of skull and long bones.)

The third series is from the temporal bone of a male, aged 41. (Oto¬
sclerosis.) This series of otosclerosis was selected because it showed the
general affection of the capsule of the labyrinth.

The most obvious feature in the microscopic appearance of the affected bone
in both diseases is the osteoporosis, which affords the main point of similarity.

In these specimens the trabecul® of bone in osteitis deformans are some¬
what coarser, and the lamellae more distinct than in otosclerosis. In some
parts the bone has almost entirely disappeared in both diseases.

The sharply defined limits of the osteoporosis are readily seen in oto¬
sclerosis, but in osteitis deformans they can only be detected by a careful
search. The dense bony capsule of the labyrinth seems to afford most
resistance to the progress of osteitis deformans, as it is only in this part
that I am able to detect this limitation, which is always somewhat indefinite
in this disease.

The large osteoclasts, very obvious in all the sections, are more numerous
in otosclerosis. The proliferation of fibroblasts is more evident in otosclerosis,
but the fibrous tissue is a more prominent feature in osteitis deformans. Here
and there the large spaces in the affected part are in intimate relation to the
endosteum. In both diseases, the irregular outline and denser staining of the
bone in relation to the endosteum indicate new bone-formation and an invasion
of the labyrinthine space. In the series of sections of one of the cases of
osteitis deformans (second) the space has been encroached upon to a con¬
siderable degree.

In both osteitis deformans and otosclerosis, in the specimens imbedded in
celloidin there is a deposit of material, probably fibrinous (Gram-positive), in
the perilymphatic space.

i This paper will be published in full in the Journal of Laryngology and Otology.

MY—Ot 1 f February 16, 1923.

Jenkins: Otosclerosis and Osteitis Deformans

The stapes is not affected by the disease in either case of osteitis deformans,
and is apparently free.

The microscopic appearances are the same in sections of long bones and
skull bones.

Clinical Aspects .—Before making a comparison, let me define first what is
meant clinically by otosclerosis, and, secondly, what I mean by the expression
14 otosclerosis group.” I need not detail the text-book description of oto¬
sclerosis, but I may draw attention to certain features that seem to me
important. First among these is the Rinne test 1 in typical otosclerosis. A
negative Rinne to low tones (say below 200) is one of the earliest definite signs.
As the disease progresses, the “ negative Rinne limit ” becomes higher, until it
may reach the highest tones of the Edelmann series of forks. This is also the
case in middle-ear deafness, but there is an important difference in that the
Rinne is negative, with a much slighter degree of deafness in otosclerosis than
in any form of obstruction deafness.

Bone-conduction is usually if not always diminished in otosclerosis. This
is more evident with low than with high tones, and may be found with
low tones only.

The low tone limit is always raised in typical otosclerosis, whereas the high
tone limit is only very slightly affected.

In typical otosclerosis cases the patients hear better with electrical aids ;
this fact often constitutes a useful test.

The study of otosclerosis has led me to believe that the symptoms and
signs of typical cases are due to the site of activity of a disease which can
produce other forms of deafness, if it occurs in other parts of the labyrinth.
Otosclerosis, as is ordinarily understood, is but one of several forms of deafness
that may be produced by the same disease.

Although this paper is not primarily concerned with otosclerosis, it is
necessary to consider what are the other types of deafness of the otosclerosis
group, otherwise it will be impossible to attach a proper value to the various
features of the deafness of osteitis deformans.

A few cases of otosclerosis which I have been able to study from the very
onset of the disease have begun as cases of pure internal ear deafness. 2

These patients consulted me, for the most part, because other members of
the family were very deaf, and they wished to know whether or not they were
themselves affected. In one instance the patient came on account of tinnitus
in herself with a history of deafness in her family.

It is not uncommon to find typical otosclerosis in one ear, and only loss
of bone conduction in the other. Moreover, a patient with intimate relatives
affected with typical otosclerosis may himself have internal ear deafness.

We are all familiar with that form of deafness in which the symptoms
and signs of internal ear deafness and otosclerosis are mixed in varying
proportions.

Although this is a subject of vast extent, I hope that I have been able
sufficiently to indicate the way in which I have come to look upon oto¬
sclerosis as an accident of disease rather than a disease sui generis , and to
regard it as one only of the many forms of deafness that may be due to a
common pathological process.

1 In testing all patients it is my practice to use Edelmann’s forks and whistles, and the
monochord.

2 Mr. Cheatlc informs me that Laidlaw Purvis held this view.

Section of Otology

For the present I propose to speak of these forms of deafness as the
deafness of the otosclerosis group.

The Deafness Associated with Osteitis Deformans.

I have found that in all cases of osteitis deformans in which the skull
bones were affected to a marked degree, the patients were invariably deaf.
The difficulties of a study of this deafness are obvious; most of the patients
were old and often the mental condition was not sufficiently good to allow of
a really detailed examination.

The following are notes of nine cases of deafness associated with osteitis
deformans; four of the patients were shown at the last meeting of the Section.

(1) A. C., female, aged 62. Operation by Sir Watson Cheyne, May,
1894. Swelling about 3 in. long pushing behind the malar bone; slightly
pushing up inferior wall of orbit. The right alveolus greatly affected. Tears
overflow. At operation bony tumour of anterior wall of antrum was
removed. Deafness : Eight gradually, thirty years ; left, five years gradually.
Paracusis very definite, nil in family. Earache: No, in childhood 4-.
Discharge: No, never. Tinnitus: Bumbling at times. Vertigo: No. Head¬
ache : No. Lump in cheek began at age of 15 ; spread along right zygoma.
No increase in size of head and no changes in limb or body noticed by patient.
Eadiograph of the head, shown at the last meeting of the Section, shows bone
changes typical of osteitis deformans. Weber: To right side. Einne:
Negative to all tones in both ears. Bone conduction: Diminished 5 to
10 secs, in both ears. High tone limit: Slightly down in both. Low tone
limit: Eaised to about 190 d.v. in both. Conversational voice: Eight, 2 in.;
left, l£ ft. Whisper: Eight, 1 in.; left, l£ ft. After inflation slight improve¬
ment in hearing. Hears much better with electric aid. Paracusis test +.

(2) W. P., male, aged 64. Mental condition fairly good. Deafness : One
and a half years, gradually worse; thinks he hears better when in a very
noisy place; no history of deafness in the family. Earache: No, never.
Discharge: No, never. Tinnitus: No. Vertigo: No. Headache: No.
Weber: To left side. Bone conduction : Slightly diminished in both. Einne:
Negative to tones below about 190 d.v.; more definitely so in left than right
ear. Low tone limit: Eaised in both ears to about 190 d.v. High tone
limit: Down in both. Conversational voice : Eight, 3 ft.; left, 2ft. Whisper:
Right, 2 ft.; left, 1 ft. After inflation—Conversational voice: Eight, 4 ft.;
left, 6 ft. Whisper: Right, 3 ft.; left, 3 ft. Test for paracusis: In loud
noise—Conversational voice : Right, 4 ft.; left, 6 ft. Whisper: Right, 2 ft. ;
left, 4 ft. (Heard better than normal individual.) Hearing slightly better
with electric aid.

(3) J. J., male, aged 62. Mental condition good. Deafness: Five to six
years; gradually worse ; right equals left. Paracusis: Three to four years;
nil in family. Earache: In childhood. Discharge: Not recently. In child¬
hood + in both. Tinnitus: “ Rushing of water ” for years. Vertigo : No.
Post-suppurative effects in the middle ears on both sides. Weber : To left.
Rinne: Negative to all tones of Edelmann series in both ears. Bone
conduction: Diminished; right, 15 secs.; left, 19 secs. Low tone limit:
Right, 100 d.v.; left, 190 d.v. High tone limit: Very much down in
both. Conversational voice : Right, 2 ft.; left, 1 in. Whisper: Eight, li ft.;
left, 1 in. After inflation—Conversational voice: Right, 4 ft.; left, 3 in.
Whisper : Right, 2 ft.; left, 1 in. Paracusis test in engine room—Conversa-

Jenkins: Otosclerosis and Osteitis Deformans

tional voice: Right, 6 ft.; left, 4 ft. Whisper: Right, 3 ft.; left, 6 in.
Hears much better with electric aid—Conversational voice : Right, 9 ft. + ;
left, 9 ft. +.

(4) P. P., female, aged 89. Memory bad, history not reliable. Right
tympanic membrane: Opacities. Slight swelling posterior wall of the meatus
and also in anterior wall in region of the outer margin of the tympanic plate.
Left similar to right- Swellings not so marked. Weber: To right. Rinne :
Negative in both to all tones below 512 d.v.; neutral to C3 in both. Bone
conduction : Diminished, both 50 to 60 secs. ; C3 fork : Right, 20 secs.; left,
*12 secs. High tone limit: Very much down in both. Low tone limit: Up to

190 d.v. in both. Conversational voice : Right, 1 in.; left, 2 in. Whisper :
Right, touching; left, touching. Paracusis test — Conversational voice:
Right, 1 in.; left, 1 ft. Whisper: Right, touching; left, touching. Hearing
distinctly better in noise.

(5) A. J., male, aged 58. Not noticed to be deaf. Deafness: No, never.
Earache: No, never. Discharge: No, never. Tinnitus: A year ago;
buzzing. Vertigo: No, never. Headache: No. Tympanic membranes:
Opacities in both, Weber : To right. Rinne : Negative to all tones below C3*
in both ears. Neutral to C3 in both ears. Bone conduction: Slightly
diminished with Edelmann special fork. High tone limit: Slightly down.
Low tone limit: Good. Conversational voice: Right, 24 ft.; left, 24 ft.
Whisper: Right, 21 ft.; left, 21 ft. (after inflation).

(6) H. A., male, aged 69 years. Mental condition fairly good. Irritable.
Deafness: Six weeks in both ; similarly six years ago; better hearing in
quiet; worse with a cold. Earache : No, never. Discharge: Both recently
and six years ago. Tinnitus: No. Vertigo: Dizziness. Has bad heart
disease. Tympanic membranes : Opacities. Weber : Right equals left. Rinne :
Right negative to 512 and all tones below; left negative to 190 d.v. Bone
conduction: Diminished, right 10 secs.; left, 12 secs. High tone limit: Very
much down in both. Low tone limit: About normal in both. After inflation—
Conversational voice : Right, 24 ft.; left, 21 ft. Whisper : Right, 18 ft.; left,
12 ft. Paracusis test in engine room—Conversational voice; Right, 12 ft.;
left, 12 ft. Whisper: Right, 1 ft.; left, 1 ft. In case of normal ear—
Conversational voice : Right, 12 ft.; left, 12 ft. With electric aid—Whisper:
Right, 21 ft. + ; left, 15 ft.

(7) L. D., female, aged 45. Osteitis deformans and acromegaly. Deafness :
Very slight, noticed three years. Earache: In childhood +. Discharge : Never.
Tinnitus : No. Vertigo : Three years off and on ; ? cardio-vascular. Tympanic
membranes: Opacities in both. Weber: To right side. Bone conduction :
Diminished in both about 15 secs. Low tone limit: Good in both. High
tone limit: Slightly down in both. Rinne : Positive to all tones. Conversa¬
tional voice: Right, 36 ft. + 1 ; left, 36 ft. +. Whisper: Right, 36 ft.; left,
24 ft. • Paracusis test, in slight noise—Conversational voice: Right, 15 ft. -f ;
left, 15 ft. + Whisper : Right, 3 to 4 ft.; left, 3 ft. In loud noise—Conversa¬
tional voice: Right, 15 ft.; left, 15 ft. Whisper: Right, li ft. ; left, 1 ft.
Compared with normal ear test at same time about equal. Hears better in
left ear with electric aid.

(8) T. H. M., male, aged 63. Has had hemiplegia. Mental condition poor.
Deafness : Slight until one and a half years ago, and much worse about a year ;
hears better in the noise of street traffic ; nil in family. Earache : No, never.
Discharge: No, never. Tinnitus: No. Vertigo: No. Tympanic membranes:

Section of Otology

Opacities in both. Weber: Right equals left. Rinne : Positive in both to all
tones above 190 d.v. ; lower tones not tested. Bone conduction : Diminished ;
right, 10 secs.; left, 10 secs. Low tone limit: Doubtful. High tone limit:
Very slightly down. Conversational voice : Right, 3 ft.; left, 9 ft. Whisper :
Right, 2 ft. ; left, 9 ft. Does not hear better with electric aid. Paracusis
test +. Conversational voice: Right, 6 to 9 ft.; left, 9 ft. +.

(9) G. F. J., male, aged 76. Could not obtain history. Tympanic mem¬
branes: Opacities in both. Weber: To right ear, all tones. Rinne: Negative
to highest tones in both ears. Bone conduction : Diminished ; right, 56 secs. ;
left, 60 secs. High tone limit: Right, C3 heard, but limit very much lower
than normal; left, some tones heard about C2. Conversational voice: Right,
2 in.; left, noise. Whisper : Right and left. Paracusis test (engine room )—
Conversational voice : Right, 3 in.; left, hears voices. Seemed to hear better
in noise.

An analysis of the cases above described will show that A. C., W. P., J. J.,
A. J., P. P., might well be described as having the symptoms and signs of
otosclerosis with internal ear deafness more prominently marked than usual.
The symptoms and signs in H.A., are those of an early case in the oto¬
sclerosis group. H. T. M. is difficult to classify, and in G. F. J., the condition
is similar to that found in an advanced case of otosclerosis in an old patient.
L. O., has internal ear deafness only, such as may he found in some members
of the otosclerosis group.

If we include Mr. Mollison’s case, we have ten cases of deafness associated
with the disease osteitis deformans, of which the greater proportion have
some clinical features similar to those of otosclerosis, in some cases obscured
by a greater degree of internal ear deafness than is usually found in this
condition.

I have examined only nine cases of osteitis deformans from the otological
standpoint. They all had obvious affection of the skull bones, and they toere
all suffering from deafness in some degree and I think it may be accepted that
deafness is not obvious until the skull bones are affected.

There was no recorded history of deafness in the family in any of these
cases.

Since in osteitis deformans, the disease in the early stages probably
involves the labyrinth at some distance from the foramen ovale, the internal
ear deafness may be expected to be more prominent than would be the case
had the foramen ovale been involved at the onset.

How far age-deafness may be a complication in these cases I am not
prepared to say. Perhaps in some cases the overgrowth of bone at the internal
auditory meatus (which is common) exerts a pressure on the auditory nerve
and so influences the nature of the deafness (? in G. F. J.).

Though ten cases may not seem sufficient to justify a definite statement
yet when the above is taken into consideration I think it is very likely that
probably these cases really illustrate the character of the deafness found in
osteitis deformans and are not accidental.

Conclusions.

There is a similarity in the microscopical appearance of the diseased hone
in osteitis deformans and otosclerosis. There are differences that may be
of great importance, or merely accidental, depending on difference of age,

Jenkins: Otosclerosis and Osteitis Deformans

activity of the disease, or other causes. The deafness found in all cases of
osteitis deformans, affecting the head in a marked degree, has some characters
of typical otosclerosis deafness.

It. is necessary to beware of the danger of attaching too. much value :o
mere similarity, but if there is a certain degree of similarity, clinically and
pathologically, then it is natural to ask what is the outcome of these
observations. Can the two conditions be identical ?

Against this possibility is the absence of any hereditary tendency in
osteitis deformans. Otosclerosis usually begins in early life and osteitis
deformans is usually recognized late in life, though the latter has been found
to appear before the age of twenty. The general affection of the bones of
the body in osteitis deformans is in contrast with the localized affection in
otosclerosis. We do not find any family history of otosclerosis in osteitis
deformans.

If these two diseases are due to the same fundamental cause, then the
difference in distribution must depend on the individual, and in “ otosclerosis ”
the peculiarity (probably anatomical) that renders the individual liable to the
affection must be hereditary.

Lastly, the causes of these bone diseases may be quite distinct, but it is
one characteristic common to both that produces the changes in the labyrinth
and the consequent similarity of the deafness.

DISCUSSION.

Sir CHARLES Ballance (Chairman) said that he was very glad Mr. Jenkins was
taking up this subject and hoped he would continue his research into the intimate
pathology of these two diseases, especially ostetitis deformans. He trusted that when
the intimate pathology* was known it would be possible to cure, or at least arrest the
disease. In the old days he (Sir Charles) had himself operated on this class of case,
and had always found that he could not get beyond the disease in various parts of
the «kull; local recurrences took place.

A feature of interest was the fibrinous deposits. Such deposits usually indicated
inflammation, and if that were so in these cases the discovery might lead to some
method of elucidating the real nature of these processes.

Dr. ALBERT A. Gray said he believed this was the first time there had been an
actual demonstration of the similarity of the changes in Ixme in otosclerosis to those
in other diseases of bone, though, of course, the similarity had been suspected.
He (Dr. Gray) himself had suspected that there might be a similar change in cases of
locomotor axaxy in which spontaneous fractures occurred. The specimens and cases
showed definite otosclerosis ; there was the sharp line of demarcation, the absence of
an inflammatory zone. He had been interested in seeing Mr. Jenkins demonstrate the
osteoclasts, because Manasse held that these were not present, bone being absorbed by
simple pressure. But he (Dr. Gray) had demonstrated osteoclasts, and now Mr. Jenkins
had done so also. He (Dr. Gray) did not agree with Mr. Jenkins that otosclerosis began
with evidence of nerve deafness, and it would be a very difficult point to prove. The
earliest case of otosclerosis in which he had cut sections was one in which the deafness
had existed three years, and in that case there had been a very definite change in the
bone. He thought that in all otosclerosis cases, and perhaps in osteitis deformans too,
there* might be a nerve disease, but not a disease of tin* cochlear branch of the auditory
nerve. The views of pathologists as to the causation of osteitis deformans would be
interesting ; possibly that disease and otosclerosis might be grouped together. They
might be nutritional diseases, i.e.. the nerves governing the blood supply and the
general nutrition of the bone and other structures might be affected in both diseases:
lie suspected that was the secret in otosclerosis. It would also be interesting to know
whether there was any other disease in bone like that in otosclerosis.

Section of Otology

Mr. SYDNEY Scott said that about twenty years ago he had examined six cases of
osteitis deformans, and made many visits to infirmaries looking for cases. One of the
male patients whom he had examined had subsequently died and the skeleton had been
placed in St. Bartholomew’s Hospital museum. In 1907, he (Mr. Scott) had cut some
sections of one of this man’s temporal bones and they exactly resembled the first one of
Mr. Jenkins’ present series. The decalcified bone was embedded and cut in paraffin,
which yielded thinner sections than those embedded in celloidin, but they were much
more difficult to prepare. He (Mr. Scott) could confirm Mr. Jenkins’ observation on
the stapes; in his own case the stapes was not ankylosed but was absolutely normal,
thus differing from what was seen in the specimens of otosclerosis. The osteoporosis of
osteitis deformans was diffuse ; he had cut sections from the tibia, and one could
scarcely tell the difference under the microscope between the tibia and the affected part
of the petrous hone. He had seen osteoclasts, which Mr. Jenkins also described.
With regard to the hearing tests, in 1908, he had no Bezold forks, but had used ordinary
tests and could not distinguish the deafness of these cases from ordinary senile deafness.
It was curious that patients with osteitis deformans should so often become affected by
malignant disease. He (Mr. Scott) thought that the occurrence of the fibrinous exudate
in the cases shown by Mr. Jenkins might prove to lie a pure coincidence; he did not
think that changes in the labyrinthine fluid were necessarily connected with the osseous
changes. In cases of osteitis deformans the patients often died from some intercurrent
terminal disease, such as pneumonia, or bronchitis, which might possibly affect fluid
tissues.

Mr. Ritchie Rodger asked whether he rightly understood Mr. Jenkins that there
was no history of hereditary disease. Osier had stated that there had been seventy-five
cases recorded, and that at least six of these had shown a definite hereditary history.
In the article referred to, by Emerson, leontiasis ossium and acromegaly were grouped
with the diseases now under discussion. He (Mr. Ritchie Rodger) thought physicians
were now inclined to attribute osteitis deformans and leontiasis ossium to a disturbance
in the proportions of the secretions of the internal glands. Possibly some elucidation of
the pathology of otosclerosis might come along this line.

Sir James Dundas-Grant described a case of a lady in advanced middle life, com¬
plaining of deafness and presenting the features of osteitis deformans. Her deafness was
a combination of obstructive and nerve deafness, and the hearing was improved to
nmie extent by the Eustachian catheter and bougie (the Eustachian tubes being
extremely narrow, suggesting some narrowing of their osseous portions). Bone con¬
duction was diminished, and there was deafness for all tones higher than 7 and 6 of
Galfcon’s whistle, pointing to a lesion of the cochlea. The percentage of duration of
hearing for a series of nine tuning-forks is shown in the accompanying charts, a la
Hartmann and Gradenigo (figs. 1,2, p. 28). In this case an interesting complication was
the occurrence of malignant disease, involving an amputation through the thigh.

Another case was that of a man of great intellectual ability, suffering from deafness
and well-marked osteitis deformans. The right ear was quite deaf to all tones,
including those of Galton’s whistle. In the left ear hearing was greatly reduced, and
Gallon's whistle was not heard above the mark 5*1. Rhine was negative for Cl, bone-
conduction slightly increased. The malleus under Siegel’s speculum was fixed on both
sides. The left Eustachian tube was only very slightly narrowed, and hearing was
improved after inflation (even for Galton’s whistle) to a greater degree than the mere
inflation would account for, the improvement which he alleged indicating a functional
clement. There appears to have been a “ middle-ear ” defect, and. as shown by the
complete and rapidly developed deafness in the right car and the lowered Galton on the
Ml, a diseased condition of the internal ear such as the changes demonstrated by
Mr. Jenkins would explain. The chart (fig. 8, p. 28) shows duration of hearing for a
series of nine tuning-forks.

He (Sir James Dundas-Grant) had had a case under his care when he was in
general practice, of a patient suffering from deafness, vertigo and optic neuritis. He
had made a diagnosis of cerebellar tumour, and overlooked the co-existent osteitis
deformans. At a hospital the osteitis deformans had been diagnosed and the cere-
Mlar tumour overlooked. The osteitis deformans and the cerebellar tumour were both
discovered at the post-mortem examination in an infirmary.

Jenkins: Otosclerosis and Osteitis Deformans

Section of Otology

the labyrinth at the situation indicated, but the deposit was Gram-positive in staining,
and this was a selective stain for amorphous fibrin. Whether it was accidental
or a part of the disease was a difficult question. It might be because these patients
were old subjects that fibrin was deposited in the labyrinths, or the deposit might be
peculiar to otosclerosis and osteitis deformans, and might be an important factor in
the pathology. In two of the cases he showed at the last meeting the pituitary fossa
was distinctly enlarged, and one case was obviously a mixed one, having both osteitis
deformans and acromegaly. At a former meeting of the Section Mr. Mollison had
shown a case having some of the characters of otosclerosis; this paper was the result,
of the stimulus derived from that case.

Case of Necrosis of the Left Temporal Bone, involving
Facial Nerve and Labyrinth, following Triple Infection
of Scarlet Fever, Measles and Diphtheria, in a Child
aged 7.

By J. F. O’Malley, F.R.C.S.

March 7, 1922: Admitted to Willesden Municipal Hospital with scarlet
fever and measles (co-existent). Been ill four days. Temperature normal.
(Under care of Dr. W. J. J. Stewart, Medical Superintendent.)

March 14: Temperature 103° F. March 15: Temperature 104° F.
March 16: Temperature 105° F. Apparently very severe attack of measles.
March 22: Nasal discharge and left otorrhcea; purulent conjunctivitis right
eye; trace of albumin in urine. March 23 : Throat inflamed ; swabs from
nose, throat and ear: positive to Klebs-Loefller bacillus ; 8,000 units of anti¬
toxin given twice on that day. March 24: Redness behind left ear over
mastoid ; left facial paralysis; incision down to bone under general anaesthesia;
no pus; wound packed and fomented; hearing normal (W. J. J. S.). March 25 :
Temperature down to 100° F. Less nasal discharge. March 28 : Left; facial
paralysis continues; in mastoid wound large area of dead bone is seen; hear¬
ing impaired left side. March 29 : Antrotomy; no pus in antrum or mastoid
cells (W. J. J. S ).

April 1 : Case seen by myself. Wound very unhealthy and not
granulating; area of dead bone large and apparently affects whole of mastoid
process.

May 13 : Chicken-pox. May 25 : Swelling behind right ear ; incision down
to bone and pus evacuated under local anaesthesia; swab negative to Klebs-
Loeffler bacillus (W. J. J. S.); healed uninterruptedly.

June 1: Floor of left mastoid wound occupied by dead bone.

July 15 : Sequestrum of bone separated.

September 15: Large piece of bone separated; more dead bone in deeper
parts.

December 7 : Operation. There was a depressed irregular wound, scarred
at the edges, with pus and dead bone in the centre; under general anaesthesia
scarred edges resected and trimmed; dead bone removed; plastic of external
meatus done and post-aural wound closed ; drained through ear as in radical
mastoid.

January 25, 1923 (present state): Wound healed ; slight discharge from ear
occasionally ; facial paralysis less apparent. Vestibular test: Cold caloric, no
response; C2 tuning-fork (right ear closed) not heard.

30 Banks-Davis: Laceration of Meatus and Tympanic Membrane

DISCUSSION.

Mr. O’Malley said that he had made inquiries about symptoms suggesting that
the labyrinth was affected before he saw the case. The Medical Superintendent said
there were several attacks of retching on the night of March 24-25, twenty-four hours
after the onset of the mastoid condition; during the period of the mastoid condition the
child was very ill, and could not swallow food, but was nourished with saline and
glucose for ten days.

Mr. Mark Hovell said that for a long time past he had felt it greatly to be
regretted that the disinfection of the naso-pharynx was not universally regarded as a
routine treatment in cases of measles, scarlet fever and some other infectious diseases.
If this were systematically done, he believed it would prevent middle-ear complications
in many cases. Disinfection was easily done by spraying collosol argentum through
the nostrils.

Sir Charles Ballance (Chairman) said that he remembered having had diphtheria
long ago, before the days of the antitoxin, even before the organism had been isolated;
his nose had been sprayed with sulphurous acid, which was very unpleasant, but might
have been effectual, as he had no mastoid or ear trouble afterwards and had made
a good recovery.

Parotid Fistula in the Scar of an Old Mastoid Wound.

By H. J. Banks-Davis, M.B.

PATIENT, a woman, aged 23 ; has had operations on both mastoids. Two
operations have been performed on the left side.

The secretion exudes from a pin-point depression at the lower end of the
scar on the left side. The flow is periodic and “ occurs when she is eating.”

Mr. Norman Patterson has shown a similar case—the condition is not
uncommon.

Laceration of Meatus and Tympanic Membrane produced
by a Celluloid Knitting Needle.

By H. J. Banks-Davis, M.B.

PATIENT, a woman, aged 40. Severe haemorrhage, continued for several
hours: the meatus had to be tightly plugged in order to arrest it. It was
venous bleeding, and the question is : “ What was the source? ” Blood came
down the Eustachian tube. The patient is well now, except for vertigo. It is
unlikely that the jugular bulb was injured.

DISCUSSION.

Mr. J. F. O’Malley referred to a similar case of injury to the tympanic membrane,
in which there were symptoms of the same kind, though the heemorrhage was not so
severe as in Mr. Banks-Davis’s case. There was, however, considerable vertigo.
He (Mr. O’Malley) had often wondered what was ,the pathological lesion which caused
the vertigo.

Sir Charles Ballance (Chairman) said that he remembered the case of a nurse
at St. Thomas’s Hospital, long ago, whose ear had been syringed by another nurse
with a long-pointed syringe, which slipped and went through the tympanum, impinging
on the inner wall. The patient fell down as if she had been shot, and had very severe
vertigo for a long time ; she could not resume duty for eighteen months.

Section of (Stolon.

President—Sir Charles Ballance, K.C.M.G., M.S.

Case of Acusticus Tumour (Right) ; Operation by Sir Victor
Horsley in 1912 ; Removal of Tumour; Recovery.

Shown by F. J. Cleminson, M.Ch.

(Report by Dr. F. M. 11. Walshe.)

DURING the summer of 1912, the patient (a personal friend of the exhibitor)
suddenly realized that he had taken to applying the telephone receiver to his
left ear, instead of to his right as had been customary. On investigation
he found that the right ear was almost completely deaf. In August of that
year he began to notice transient amauroses on any exertion, and by November
it became apparent that his vision was failing. Examination by Dr. T. R. Elliott
at this time revealed, in addition to deafness of the right ear, double optic
neuritis. Weakness and unsteadiness of movement in the right arm, and some
unsteadiness of gait developed at this time, and a diagnosis of right-sided
acusticus tumour having been made, he was operated on by the late Sir Victor
Horsley in December, 1912, and a large tumour was removed. Mr. Wilfred Trotter
was present at the operation. Following operation, a right-sided facial palsy of
peripheral type appeared, and there was for some weeks profound cerebellar
ataxy of the right limbs. This slowly regressed during the spring of 1913.
From 1913 until 1917 the patient lived an active open-air life in New Zealand,
and is now continuously engaged in business.

He has kindly submitted himself to examination, and his present state is as
follows: He expresses himself as physically fit, and as conscious of no mental
or emotional change from his condition prior to the development of symptoms
in 1J12. There is an occasional cloudiness of vision in the right eye, and the
right ear remains completely deaf. The facial weakness has ceased to improve.
He is free from headache or other signs of increased intracranial tension, and
the small cerebral hernia now present never varies in size nor becomes tense.
In writing he is conscious of some clumsiness of the right hand, and he can
only play slow pieces on the piano, as on rapid movement the movements of
the right hand and wrist become ataxic. His gait is normal, but he cannot kick
a* football with his right foot with any degree of precision. His golf has become
very uncertain since his operation. He can make a series of strokes with his
old facility, but is liable to sudden periods in which he becomes very wild and
inaccurate in his play.

Examination reveals a small flaccid swelling over the right cerebellar fossa
overlying the bone defect. The optic discs show some posfc-papillitic atrophy,
but there is no swelling and on rough tests vision is good in both eyes.
The right ear remains completely deaf. The pupils are normal and ocular
movements are of good range and association. On deviation to the right there
is a slow wide nystagmus, but no definite nystagmus at rest or on looking to
the left. There is loss of sensibility to light cotton-wool touch over the
distribution of the right fifth nerve, and also to pinprick and to thermal

Jy—Ot 1 March 16, JG23.

Cleminson—Walshe : Acusticus Tumours

sensation. The right corneal reflex is absent. Pressure sense remains.
The motor fifth is intact. There is marked paresis of the right face, with
occasional fibrillary twitchings of the paretic muscles. The other cranial
nerves are normal.

There is slight defect of co-ordination in the right hand, shown as dysmetria
and dysdiadochokinesis, and on passive movement there is slight hypotonia of
the right arm. These defects are minimal, and do not constitute a grave
disability. No demonstrable abnormality in this respect is appreciable in the
right leg, and there is no true weakness of the right limbs. The tendon-jerks
are brisk and equal on the two sides, and the plantar responses are flexor.

There is a “ nystagmus ” of the pharyngeal muscles of the right side.

Specimen of Brain and Acusticus Tumour,

Shown by F. M. R. Walshe, M.D,

(Introduced by Mr. F. J. Cleminson.)

The temporal bone shows a dilatation of the internal auditory meatus.

The case from which this specimen was obtained is alluded to in
Dr. Walshe’s paper.

Acusticus Tumours.

By F. M. R. Walshe, M.D.

The appearance within the past few years of two important contributions
to the subject of acusticus tumours (I refer to Cushing’s book, 1 and to Mr. Fraser’s
paper, read before this Section *) has left little to be said, and I have no original
information to impart, but it maybe of some use to emphasize certain points in
the clinical picture, and to make some observations on the functional examination
of the labyrinths in the light of the work of Magnus and de Kleijn. To my
mind this work has shown the inadequacy of what has hitherto been regarded
as a complete investigation of labyrinthine functions, and has revealed in a
remarkable manner, and for the first time, the complex character of labyrinthine
activities.

In its most characteristic form the clinical course of a case of eighth nerve
tumour is well known and easily recognizable. From the fact that the tumour
arises on the nerve itself, and on that part of it which lies in the internal
auditory meatus, it is not surprising that symptoms referable to the eighth
nerve should usher in the malady. These symptoms are progressive deafness
with or without tinnitus. It is usual to regard tinnitus as an irritative symptom,
and, in respect of the cochlear division, we should expect stimulation of the
nerve to produce some such symptom. It must be remembered, however, that,
in general, neurological experience does not readily favour the idea of “ irrita¬
tion” as an explanation of a symptom which may persist continuously for
years, and is associated with a very slowly progressive pathological process.
Such symptoms are more commonly found with acute or rapidly progressive
lesions, and tend to be intermittent and transient. In this connexion we may
note that tinnitus is not a constant symptom, and when it does occur it may
be long delayed. While, therefore, I have no alternative explanation to provide,
we should not assume as a matter of course that tinnitus indicates what is

1 Cushing, “ Tumours of tlu- Nervus Acusticus,” Philadelphia, 1917.

• Proct t ilinr/x, 1920, xiii (Sect. Otol.), p. 109.

Section of Otology

3 *

loosely called “ irritation ” of the auditory branch of the eighth nerve. Nor is
it always easy to establish deafness as an initial symptom, for deafness, like
unilateral blindness, may pass unnoticed by a patient until revealed by
examination. With regard to the vestibular division of the nerve, I think
vertigo is the only symptom we can definitely attribute to this branch. Only
now, in the light of Magnus and de Kleijn’s work, are we in a position to
differentiate between cerebellar and labyrinthine defect-symptoms with any
degree of accuracy, and the evidence indicates that ataxy in movement,
nystagmus, and muscular atonia or hypotonia are cerebellar in origin and not
labyrinthine. Magnus and de Kleijn have found that throughout the whole
animal scale, from guinea-pig to ape, nystagmus is merely an immediate and
very transient result of unilateral labyrinth extirpation. The sole permanent
system i3 rotation of the head—so that the face points away from the side of
the lesion—with some inclination of the head towards the affected side. In
man this amounts to turning of the chin away from the lesion, and a lowering
of the occiput towards the side of the lesion. This is a relatively common
manifestation in cerebellar lesions, and is spoken of as a cerebellar symptom.
When we recall the fact that the study of cases of tumour and gunshot wounds
provides us with the bulk of our clinical material, it is apparent that in both
instances involvement of the labyrinth or of the eighth nerve is to be anticipated,
and therefore it seems probable that the so-called cerebellar position of the
head is a sign of unilateral labyrinthine defect. Loss of muscle tone does not
appear to be a direct result of labyrinthine extirpation, but when present it is
due to the rotation of the head, which sets up what Magnus has called a
‘tonic neck reflex.” This reflex, in turn, produces diminution of tone in the
extensor muscles of the limbs on the side of the lesion. I would, therefore,
say that deafness, tinnitus, vertigo and inclination of the head are the symptoms
definitely indicative of progressive paralysis of the two divisions of the eighth
nerve. It may happen that these four symptoms long antedate the appearance
of other focal symptoms, and when this is the case we may rightly speak of an
initial or “otological stage” of the disease. So far, despite the exhaustive
nature of the tests employed for the functional assessment of the eighth nerve,
I have not met with a case of eighth nerve tumour recognized as such during
this stage. I do not level this as a reproach at otologists or neurologists, for
I believe that it would be very difficult to persuade the surgeon to act upon
even the fullest information obtainable at this stage.

The next group of symptoms to appear, when the malady follows its usual
course, are those referable to progressive paralysis of function in cranial nerves
adjacent to the eighth nerves , and in the cerebellum. The first of the cranial
nerves to show signs of involvement is usually the fifth. Here, again, the
symptoms may be grouped as irritative and paralytic. Among the symptoms
actual pain is not common ; the patients complain rather of abnormalities of
sensation, such as numbness, creeping sensations in the skin, and so on. In
one case under my observation, the patient first sought advice for a distressing
feeling of numbness over the right cheek, and, among other diagnoses, that of
an infected antrum was made. This may seem a trivial symptom to attract
much attention, but anyone who has endured the application of cocaine by a
dentist will know bow obtrusive and annoying a small patch of anaesthesia on
the face may be, and indeed this patient was found to have sensory loss and
absent corneal reflex on the right side, physical signs which, had they been
looked for, would have betrayed the nervous origin of the symptoms. It is
commonly said that diminution or absence of the corneal reflex is the initial

Walshe: Acusticus Tumours

defecfc-symptom in progressive fifth-nerve lesions, and in the case of which the
specimens are shown to-night this was the only objective sign referable to the
sensory division of the fifth nerve within a fortnight of death. Cushing
records a similar case. The motor division of the fifth nerve is less commonly
affected, though in the case just mentioned I was satisfied that there was
slight but appreciable weakness of the masseter on the side of the corneal
arreflexia.

Next in importance, when it is present, is involvement of the facial nerve .
Facial paresis may be a long delayed sign, and is rarely profound. Generally
it consists in slight asymmetry of the lower part of the face on voluntary and
oxpressional movements. Like sixth nerve palsies, which we shall consider
next, it is apt to vary from day to day, as was strikingly shown in one case
which came under my observation. The patient was a woman with right¬
sided eighth and fifth nerve lesions and slight right-sided cerebellar symptoms.
It was not possible to say definitely whether there was or was not a slight
paresis of the right side of the face. However, a diagnosis of acusticus tumour
having been made, the question of operative treatment had to be set before the
patient, who was extremely upset and wept copiously for the rest of the
afternoon. I saw her again just after tea-time, and was surprised to observe
a profound weakness of all the facial muscles on the right side. By the next
morning this weakness had again disappeared. Undoubtedly, the violent
muscular activity entailed in her crying had brought out, by a process of
fatigue, a latent* weakness of the face. Occasionally, irritative symptoms
referable to the seventh nerve may be present in the form of clonic spasms of
the face muscles, and Cushing records that a diagnosis of Jacksonian fits has
been erroneously made and exploration of the crossed motor cortex undertaken
to reveal the cause. The mistake may seem an absurd one, but it is by no
means so. The twitching of the facial muscles may be so regular in force and
rhythm as closely to resemble a Jacksonian fit. In a fatal case of lethargic
encephalitis, which came under my observation some time ago, such a clonic
spasm of the lower part of the face on the right side was the sole focal nervous
symptom present throughout the course of the malady, and it was quite
impossible to decide whether its point of origin was the cerebral cortex or the
seventh nerve nucleus. Microscopic examination revealed an intact motor
cortex, but showed that the seventh-nerve nucleus was the seat of charac¬
teristic and well-marked lesions. It must also be borne in mind that signs
of a crossed hemiplegia may be present in eighth-nerve tumours, appearing
first as slight paresis of the face of upper neurone type; I shall later describe
such a case. It is scarcely surprising, therefore, that twitching of the face
should be mistaken for a symptom of similar localizing value in cases where
the typical picture of eighth-nerve tumour is not present.

Sixth-nerve Palsy .—Paralysis of the external rectus is relatively common,
but, as it occurs in cases of the kind under discussion, it is almost certainly
what Collier has called a “ a false localizing sign.” In other words, six’h-
nerve palsy here, as in so many other varieties of cerebral tumour, is not ihe
result of direct involvement of the nerve by the tumour, but is a general
pressure effect due, according to Cushing, to strangulation of the nerve between
the floor of the skull and the anterior inferior cerebellar artery. Its relatively
late appearance, and its tendency to fluctuation and transient disappearance,
both indicate this mode of origin.

Symptoms referable to the ninth , tenth and eleventh nerves certainly occur,
but must be regarded as terminal symptoms, rather than as aids to diagnosis.

Section of Otology 35

They are manifested as dysphagia and dysarthria, and need not be further
considered here.

Next in order of importance are symptoms dependent upon compression of
the anterior part of the lateral lobe of the cerebellum. These vary in date of
onset and in intensity from case to case, but they may be said to be a constant
part of the typical clinical picture which we are now considering. They are
referred to the side on which the tumour is situated and consist of muscular
hypotonia, an inability to perform rapidly alternating movements, a tendency
to spread of innervation to muscles not normally taking part in a particular
movement, and a tendency to error of projection, so that the patient overshoots
the mark and may deviate above or below, to right or to left of the object
aimed at. In the case of the lower limbs, this ataxy produces a staggering
gait and an inability to co-ordinate the component elements in wide move¬
ments employing the musculature as a whole, so that the patient loses balance
and tends to fall towards the side of the lesion. In the case of the muscles of
the head and neck, the same disorder of co-ordination is manifested as
nystagmus and defects in articulation. I do not propose to describe cerebellar
ataxy in greater detail, or to recite the list of polysyllabic names of Greek
derivation by which we have learned to replace a simple descriptive account.
I cannot see that such words as “ dysdiadochokinesis ” have any informative
value. On the contrary, they are apt to induce us to suppose that we have
really got to the bottom of the nervous disorders which lead to the phenomenon
in question, whereas we have not.

In short, the true focal symptoms of an eighth nerve tumour are referable
to the eighth, fifth and seventh nerves and to the cerebellum, and these
generally usher in the clinical picture and dominate it throughout its course,
and are the basis of clinical diagnosis.

We must, however, consider further the general signs of raised intra¬
cranial tension, not only because they form a part of the whole clinical picture,
but because, as we shall see, they may dominate it so greatly as to obscure the
focal symptoms. In this way they may give rise to a clinical picture widely
different from that which we have been considering. In cases of eighth-nerve
tumours, general pressure symptoms result from compression and distortion of
the brain-stem, which blocks the exit of cerebro-spinal fluid from the ventri¬
cular system and thus leads to secondary internal hydrocephalus. The
symptoms produced in this manner are headache, vomiting and progressive
impairment of vision from choked discs. In addition, there may be marked
impairment of intelligence, leading to the not unknown error of diagnosing a
frontal lobe lesion in cases of cerebellar tumour. As a rule, the true focal
symptoms have developed before the effects of general increase of intracranial
tension have reached any high degree, but from time to time general pressure
symptoms dominate the clinical picture from the beginning and the focal
symptoms may never appear to their full extent. Gordon has recently
recorded a series of cases of cerebellar tumour, including three of eighth-nerve
tumour (as far as can be gathered from his report) in which focal symptoms
were conspicuously absent throughout the whole course of the illness, and the
impression obtained is that the apparent uniformity of the clinical course of
an eighth-nerve tumour as described by Cushing and others depends in part on
the fact that cases of this lesion are not recognized as such unless this typical
clinical picture is presented. In other words, a somewhat false and deceptive
precision in our notions on the subject is apt to develop.

The case from which the specimens exhibited this evening were obtained

Walshe: Acusticus Tumours

was of such a nature, and a brief summary of the patient’s history of the sym¬
ptomatology may serve as a corrective to the simple cut-and-dried symptom -
complex we have described. The patient was a young woman who was
admitted to hospital for a uterine lesion. On admission she made no com¬
plaint of symptoms referable to the nervous system but it was observed that
she had considerable headache, appeared to have defective visual acuity and
was occasionally sick. In addition, she was apathetic and distinctly stupid.
Examination revealed a chronic otitis media with free discharge in the left
ear, which was completely deaf. There was bilateral papilloedema and gross
impairment of visual acuity. Repeated examination from day to day revealed
two other physical signs, the significance of which I freely admit I had not the
courage to face, though their possible meaning did occur to me. These were
absence of the left corneal reflex and slight paresis of the left masseter muscle.
The facial movements were normal on the two sides at first, and there was no
defect of cutaneous sensation on the left half of the face. Arm movements,
articulation and deglutition were normal. She was not taken from bed to have
her gait tested. During the week following admission, there developed a distinct
and constant paresis of the lower part of the right side of the face. On appearance
of this sign a left supra-tentorial decompression was performed, but it gave no
relief to the rapidly increasing general pressure signs, and she died comatose.

At autopsy the tumour which is now before us was found. In situation,
relations and appearance, and on microscopic examination it is clearly a
typical eighth-nerve tumour. In addition, there is seen to be some dilatation
of the ventricles and secondary internal hydrocephalus.

In this case, the presence of middle-ear disease on the left side blinded us
as to the significance of the deafness, while the absence of sensory changes in
the face induced me to hesitate to place much reliance on the loss of the left
corneal reflex, or on the slight paresis of the left masseter. It is now clear
that both were true localizing symptoms. Nevertheless, this clinical picture
is very different from that described as typical of this lesion and was
dominated throughout by the signs of hydrocephalus. The pons is seen to be
grossly distorted, and this no doubt was the source of the hemiplegic type of
facial paresis observed on the side opposite to the tumour. The distortion of
the brain-stem present in this specimen indicates also the high degree of com¬
pression that the ascending and descending paths may undergo without giving
rise to disturbances of function, and in general we may say that variations in
the reflexes, in power and in sensation in the trunk and limbs develop late
if they develop at all, and give no reliable information as to the side of the
lesion.

There is one other point to be mentioned. I do not propose to describe the
characters of the deafness found in these cases. Many of you have had a wide
experience of eighth-nerve tumours and can state whatever generalization may
be possible in the matter far better than I can, but the vestibular division of
the nerve raises some questions of physiological interest which may be worth
brief mention. We may consider the eighth nerve as composed of sensory and
non-sensory parts, namely, the cochlear and vestibular divisions. The vesti¬
bular nerve belongs to the non-sensory afferent proprioceptive system, and, as
the work of Magnus and de Kleijn has revealed, is itself physiologically dual.
It has two end-organs, subserving separable and distinct functions ; these we
may speak of as the otolith organs and the semicircular canals. These
receptors react to stimuli of different quality and give rise to reflex reactions in
the musculature of totally distinct character. The otoliths are stimulated not

Section of Otology

by movement, but by variations in the position of the head in relation to the
horizontal plane. The reflex reactions they evoke are variations in muscle
tone, and therefore in attitude, and these variations persist as long as the
posture of the head which gives rise to them is maintained. Thus a tonic
reflex arising in the otolith organ may persist for months, as Magnus has
shown. The semicircular canals, on the other hand, are stimulated by rota¬
tion or by movement in a straight line, either vertically or horizontally. The
muscular reactions resulting are not postures, but movements which cease
when the stimulus evoking them fails. Mr. Alexander Tweedie has described
these different types of reflex reaction before the Section, 1 and I shall not
recapitulate his description. The point I wish to make, and, having made it,
I shall discreetly leave the subject, is that what we commonly accept as a
complete examination of the vestibular division of the eighth nerve is
merely an examination of the semicircular canals and cannot be considered
as throwing any light on the otolith organs, the functions of which are not
less important. In other words, the work of Magnus has revealed that the
labyrinth is a dual organ physiologically, and that hitherto we have investi¬
gated but one aspect of its functions. It seems possible that a careful
investigation of the tonic labyrinthine reflexes might in these cases provide
signs of distorted function in the labyrinth at a time when the present
repertoire of semi-circular canal tests give us negative results. The elaboration
of such an examination-technique is in itself a piece of work which would be
well worth doing, if for no other purpose than that it would make otologists
familiar with the series of delightfully lucid papers in which Magnus and his
collaborators record observations which have rendered obsolete much of the
lore still passing muster amongst us as the physiology of the vestibular
nerve and the labyrinth.

Surgical Treatment of Eighth Nerve Tumours.

By Wilfred Trotter, M.S.

(ABSTRACT.)

The auditory fibroma is a benign slow-growing tumour, which is almost
invariably single. Its great seriousness as a pathological condition is therefore
due entirely to its situation. Successful operation leads to a certain cure with
very little subsequent disability. The problem as to how these tumours
should be removed is thus one which justifies the minutest attention to its
purely technical side.

It is important that the surgeon should have a clear idea of the anatomical
conditions which (a) give rise to the characteristic symptoms of the tumour ;
( b ) lead to certain important complications ; and (c) restrict and condition the
method by which the tumour is to be reached.

Of these considerations the most important are those which arise out of
the situation of the tumour in front of the cerebellum and to the side of the
brain-stem. This situation renders it necessary to approach the tumour after
dislocating the cerebellar lobe, and gives rise by pressure on the central canal
of the nervous system to the most important complication that is met with,
viz., secondary hydrocephalus and a general rise of intracranial tension.

It is when this complication is present, as it almost invariably is in the
late stages, that the operation becomes most difficult and dangerous. From

1 Proceedings, 1921-22, xv (Sect. Otol.), pp. 15, 19-2-1.

38 Trotter: Surgical Treatment of Eighth Nerve Tumours

the surgeon’s point of view it is almost impossible to exaggerate the difference
in seriousness of operations undertaken before or after the onset of secondary
hydrocephalus.

The principal features of operative technique are as follows : The patient is
in the prone position with the head flexed and supported on a separate head
rest. The intratracheal method is the most convenient for the anaesthetic.

The crossbow incision is used, and in dividing the muscles it must be
remembered that the close suture of them at the conclusion of the operation
is very important. The bone is removed so as to expose the lower edge of the
lateral sinus on each side, and to open up the foramen magnum freely.
Throughout the procedure it is extremely important to restrict the loss of
blood in every possible way. To ensure this the free use of Horsley’s wax is
most important. The dura mater is opened in the foramen magnum over the
cone of cerebellum, which usually has been displaced into the spinal canal.
The freeing of this part of the cerebellum usually results in an escape of fluid,
and a reduction of the local tension. If the tension is not reduced in this way
the lateral ventricle must be tapped through a separate opening in the bone
above the superior curved line, by means of a needle passed into the posterior
horn. When the dura has been freely opened and everything has been done
to relieve the intracranial tension, the cerebellar lobe is drawn inwards until
the tumour is reached.

It is important to remember that during this process cystic collections of
fluid are apt to be met with, and may be mistakenly regarded as the source of
the symptoms. When the tumour itself is reached, it is to be recognized by
its consistence being greater than that of the brain, by its smooth surface, and
by its fixation to the outer wall of the posterior fossa.

No attempt is made to remove the tumour intact. The capsule is opened
and its contents removed by curetting or by suction, if the latter is possible.
In favourable cases, after the substance of the tumour has been got out, an
attempt should be made to remove the capsule. This can be safely accom¬
plished in certain cases, and if it is not done a recurrence of the disease is sure
to take place sooner or later.

Throughout the intracranial stage of the operation haemorrhage is often
free, but it can usually be controlled by saline packing, and no time should be
grudged for this purpose. The dura mater is left freely open, the muscles are
very carefully sutured so as to prevent a leakage of cerebro-spinal fluid, and
the skin wound is completely closed.

After such an operation, if the patient escapes immediate effects of shock
and haemorrhage, the only serious danger is the development of oedema of the
medulla. If this does not occur within the first forty-eight hours the
prospects of a satisfactory recovery are very good.

In general it should be the object of the surgeon to complete the operation
at one sitting. He will, however, occasionally be compelled to break off on
account of technical difficulties in controlling haemorrhage or reducing intra¬
cranial tension. Such a decision should not be founded on any expectation
that a mere decompressive operation will be of any permanent benefit to the
patient, but should have in view another attempt at removal of the tumour
when local conditions become more favourable in the course of a few weeks.

DISCUSSION.

The Chairman (Sir Charles Dallance) said that he saw his first ease of tumour of
the auditory nerve as long ago as 1887. Sir Seymour Sharkey asked him to see a patient
who had come in with absolute deafness in one ear, and double optic neuritis. The case

Section of Otology

was recorded in Brain in 1889. The patient was a male, aged 41, and there had been
a gradual onset for about two years, with occasional pain in the head, and tinnitus.
He was taken into hospital. The headache increased, he had continual giddiness and
tinnitus, and ultimately attacks of unconsciousness. Six months after he (Sir Charles)
saw him, the patient began to suffer from facial palsy, and three months later he
died. The specimen was in St. Thomas’s Hospital Museum. Though Sir Seymour
Sharkey held the view, shared by others, that it was a case of tumour of the auditory
nerve, there was, at that date, no question of operation, and no physician would have
listened to a suggestion to remove such a tumour. In doing the post-mortem examina¬
tion, it was found that the tumour invaded the internal auditory meatus, which was
expanded. Radiography, and the comparison of the meatus on the two sides, were
great aids in present-day diagnosis. In Politzer’s work appeared a picture of a tumour
of the auditory nerve, about the second case he (the speaker) knew of. It was that of a
woman who had had deafness for ten years. When seen three months before death
die had double optic neuritis, soon followed by facial paralysis and dementia. The
specimen was obtained by Dr. von Millengen, of Constantinople, and sent by him to
Politzer. The internal auditory meatus was expanded by the pressure of the tumour.
In dissecting a tumour of this sort, it was a surprise to see how the facial nerve could
gradually lengthen and wander over the side of such a tumour, and how late in the
rase facial palsy might come on. It might be that this palsy supervened when
pressure from the growth in the internal auditory meatus occurred. About two years
after Sharkey’s case he saw another case, that of a woman, and she also died. He saw
the post-mortem examination done. The tumour was in much the same position, and
facial palsy only supervened three months before the end. As Mr. Trotter pointed out,
these patients often died of internal hydrocephalus. He (Sir Charles Ballance) had long
ago assisted at some of the first operations in London on eneapsuled tumours of the
j*osterior fossa. At first these tumours were avulsed much in the same way as weeds are
taken from a garden path, but fortunately a more gentle and dainty method now
prevailed, care being taken that no drop of blood should be lost. In one early case at
St. Thomas’s Hospital, when he had exposed the tumour he felt he had reached the
summit of his ambition, for he thought the growth would come aw r ay easily. He
removed it, but there was severe haemorrhage from the superior petrosal sinus. He
had seen very serious haemorrhage from the anterior inferior cerebellar artery, but that
from the petrosal sinus was more serious, as it was difficult to control. There was a
way to prevent haemorrhage in exposing these tumours which had not been mentioned.
It was a method used by Sir David Ferrier. He used marine sponges, perfectly dry.
They absorbed the cerebro-spinal fluid and compressed the brain without injuring it, and
it was a method he (Sir Charles Ballance) recommended to operators.

He agreed with Mr. Trotter as to the uselessness of a decompression operation in
these cases. Decompression seldom relieved serious local pressure. With regard to
doing the operation in one stage, as Mr. Trotter advocated, that, of course, was the
ideal method, but he (Sir Charles) thought that in the two-stage operation there was
this great advantage that, if one opened the dura—and no operation was effectual
without opening the dura—the patient in some cases would stand the operation better,
before the war he knew of two cases in which the dura was not opened, and the
patient died before a second operation could be done. Many years ago he did some
experiments with Sir Charles Sherrington to see w r hat w ould be the effect of taking
away large portions of the skull, and how much more fluid could be introduced into
the intradural space after such a large craniotomy. They found that the amount of
fluid which could be introduced by removal of the bone alone was infinitesimal.
Therefore, it was clear that there was no relief of pressure, however large the crani¬
otomy was; the dura must be opened, or the patient was not safe.

With regard to the great discomfort of having even a small patch of anaesthesia,
mentioned by Dr. Walshe. In some of these cases there was involvement of the fifth
nerve, and the fact of the discomfort he could corroborate from his experience of a case
he saw after the South African war. A colonel had sustained a gunshot wound of the
leg, which divided the external saphenous nerve. It rendered the outer side of his
h’ffie toe and foot anesthetic, and though previously a good walker, he could not then
march more than ‘200 yards. Dr. Walshe had mentioned a case of mistaken diagnosis.

40 Trotter: Surgical Treatment of Eighth Nerve Tumours

in which spasm of the facial nerve had led to the diagnosis of cerebellar tumour being
•changed to that of a tumour above the tentorium, as it was looked upon as a Jacksonian
symptom. He (Sir Charles Ballance) had experienced that kind of mistake on more
than one occasion. He remembered two such instances which had caused him
much distress. The patients in both cases were nurses. The first had symptoms of
tumour of the brain, and much pain in the head. Dr. Hughlings Jackson, Sir William
Gowers, Sir David Ferrier and Dr. Charles Beevor all saw the patient on several
occasions, and all concluded there was a tumour in the left cerebellar fossa. He (the
speaker) removed all the bone over the cerebellum, and there was no tumour of the left
cerebellar fossa, nor of the right. Much fluid was let out. She became comparatively well
for fifteen months, and then was ill again. She came into the hospital, and died
eighteen months after the operation he had performed. An encapsuled tumour of the
meninges of the opposite frontal lobe was found which could easily have been removed.
She had had crossed cerebello-frontal headache. Three years ago a similar event
happened, and he exposed the cerebellum without finding a tumour there. In the case
of this nurse also a most careful examination was made by several neurologists and
she died about two years afterwards. There was an encapsuled tumour of the opposite
frontal lobe, and if it had been diagnosed and operated on it would have come out like
a pea from its pod.

Mr. Cleminson had just shown a patient from whom the late Sir Victor
Horsley had removed an auditory nerve tumour, and he (the speaker) had observed a
dropping of the shoulder. He believed that Dr. Gordon Holmes, in his Lectures, had
ascribed this dropping of the shoulder to hypertonia due to involvement of the cere¬
bellum. He (Sir Charles) did not remember, in any cases of tumour of the cerebello¬
pontine angle he had seen, that dropping of the shoulder was noted before the operation.
Probably this was due to a failure in observation. Therefore the case shown by
Mr. Cleminson was of great interest to him.

Dr. Gordon Holmes said that experiences differed, and certain symptoms probably
attracted the attention of some observers more than others ; but on the whole he
agreed with the clinical picture which had been put forward by Dr. Walshe and
Mr. Wilfred Trotter. He had seen a large number of cases of the kind under discussion,
especially during the last few years, and previously he had had a rather extended
experience of them as a pathologist. He had been impressed by the variability in the
shape of the tumour ; in some cases it was a firm, more or less spherical mass, in others
a growth of softer structure which moulded itself along the lateral surface of the pons and
medulla. He thought this fact was the explanation of the considerable variability of
symptoms seen in different cases ; in those in which a spherical tumour lay in the
region of the internal auditory meatus, the upper cranial nerves alone were affected,
but in many cases the early symptoms pointed to a disturbance of the lower cranial
nerves, weakness of the palate, disturbance of the movements of the vocal cords,
dysarthria and occasionally dysphagia occurring. He had that day looked through
notes on thirteen cases which he had seen in the last year or two, in all of which the
diagnosis had been confirmed either by autopsy or by operation; he found that few had
marked antesthesia on any part of the face, only a small proportion complained of pain
or numbness there, though in a large number, but not in all, the corneal reflex on the
same side was absent. Therefore it could not be said that there was always clinical
evidence of disturbance of the trigeminal nerve. In his experience the facial nerve
was more frequently involved than it was said to be by Dr. Walshe. The
extraordinary feature of these cases, to those who had the opportunity of examining
the brains after death, was the infrequency of hemiplegic or sensory symptoms on the
opposite side of the body. When one saw the side of the pons deeply excavated,
one was almost forced to the conclusion that the function of the pyramidal tract and
perhaps of the lateral fillet, must have been seriously involved, yet the proportion
of cases in which there was weakness, spasticity, changes in the reflex or any form of
antesthesia of the opposite side was very small. He had not seen any cases confirmed
by autopsy which did not present sufficient symptoms during life to justify a definite
diagnosis. In every case which had come under his observation there had been obvious

Section of Otologij

symptoms of cerebellar disturbance. Those symptoms differed in some respects from
the symptoms due to lesions of the cerebellum itself, probably because they were mainly
a result of compression of the middle cerebellar peduncle rather than of involvement of
the cerebellum. A striking feature was that there was often in these cases very little
disturbance of tone. It was perhaps presumptuous on his part to refer to the surgical
treatment, but so many of his cases had passed through the hands of surgeons that he
had had some experience in the matter. He had seen one case recover only after
gross removal of the tumour, a man upon whom Sir Victor Horsley operated many
years ago. but though he lived for several years he was seriously crippled. The danger
seemed to be that total removal necessarily meant a disturbance of the vascular supply
on the same side of the pons and medulla; the man to whom lie referred had, after the
operation, the characteristic symptoms of softening in the lateral side of the pons.
He saw a few other cases which had survived operation for a week or so after total
reino\al of the tumour, and all showed evidence of acute bulbar involvement. The
statement made by Mr. Trotter and Sir Charles Ballance as to the inefficacy of simple
decompression seemed to be borne out by every’ one who had had experience of these
cases. But here too there were exceptions. One of the most brilliant results he had
seen in the matter of surgical intervention was in the case of a man he saw with
Mr. Percy Sargent three years ago. Owing to difficulties during the operation, the
scalp was at once sewn up after the tumour had been exposed. The patient had
now lost most of his symptoms, and though he was a professional man to whom
co-ordination was important, he was going about and leading an active life. He
particularly wished to know whether in the experience of otologists there was complete
nerve deafness in all cases of auditory nerve tumour which had reached the clinical
stage at which a diagnosis could be made.

Mr. Sydney Scott said this subject interested him from the otological standpoint.
He had himself seen forty-five cases in which tumour involved the auditory nerve. He
had sections of the labyrinth showing that the growth often invaded the cochlea, and if
an attempt had been made to remove the tumour in such cases it would have been
necessary to remove the labyrinth to make sure of getting rid of the whole tumour.

Dr.Gordon Holmes had suggested that there was a period in which the diagnosis could
he made before deafness was complete: but in investigating these cases he (Mr. Scott)
had never felt justified in diagnosing such a tumour until there was almost absolute
deafness. The difficulty w as to make sure of this, because the good ear was so liable
to hear the loud tones used in testing the deaf ear. The use of the Barany noise
apparatus was limited : it excluded tones of low pitch, but it did not exclude high tones ;
in cases of intracranial tumour, when optic neuritis of high degree was present, there
was practically always diminished bone conduction, and some loss for the highest tones.
Great loss to low tones was much more consistent with the presence of auditory nerve
tumours than was taught in many text-hooks on otology. Loss to low tones was more
important as a sign of auditory nerve tumour than loss to high tones alone, of which
latter there were many causes. As a rule, the typical signs were great and progressing
loss of low tone appreciation, with diminished bone conduction, and some bilateral loss
to high tones. Preservation of low tone appreciation was unusual, but he found this in
a man who had a tumour originating not in the auditory nerve, but as a pre-pontine
intradural cholesteatoma. The mass spread to one side pressing the pons and the
auditory nerve backwards. The patient, an intelligent young man. appeared to be very
deaf for conversation; he said he could hear the sound of the voice but could not analyse
the sounds. Mr. Scott ascertained that the patient could hear, on both sides, a fork of
sixteen double vibrations per second, hut tones above 440 vibrations w ere to him an
utter blank on one side, while on the other he could hear to about 5,000 vibrations per
•**cond. As the result of Magnus’s investigations, Dr. Walshe foresaw* that our customary
vestibular tests were incomplete. Still, the caloric rotation and galvanic tests, together
with the hearing tests, sometimes took three hours for a single patient; the testing
could not be hurried or completed at one sitting, and great deliberation had to be
exercised or the results were unreliable. Sir Charles Ballance had referred to the pos¬
sible confusion of frontal and cerebellar lesions. This should be impossible. One

42 Trotter: Surgical Treatment of Eighth Nerve Tumours

patient, on whom it was proposed to operate for frontal tumour, on the left side, was
next morning sent to Mr. Scott to be tested, owing to deafness in the right ear. He
concluded there was a lesion of the right auditory nerve, because he found the vestibular
tests were negative, as in cases of labyrinthine ablation, and there was complete
absence of the galvanic test on the affected side. The physician was informed, and
the diagnosis altered. A right extracerebellar tumour was found. Another patient with
bilateral auditory nerve tumours bore a transcephalic galvanic current of 20 ma„
without any sign of vertigo or forced movements of eyes, head, &c. A 10 or 15 ma.
current in the ordinary person caused forced movements when applied to the normal
ear. He had described elsewhere the method suitable for the galvanic test. One
electrode was placed on the wrist of the side to be examined, the anode being placed
on the ear on the same side, so that the current passed through the vestibular nerve
on the side being examined. Whenever possible it was preferable that the patient be
tested standing, as weaker currents were required. The galvanic reaction had been
positive on the normal side, negative on the affected side in all cases in which the
patient had been proved to have a lesion affecting the nerve trunk. There should no
longer be any such mistake as diagnosing a frontal tumour for an extracerebellar
tumour or vice versa. Mr. Scott owed his experience of auditory nerve tumours to
his colleagues, Dr. Gordon Holmes and the physicians at the National Hospital, who
had referred so many of their cases to him for special examination. He had used
the Bezold-Edelmann tone series and the Edelmann-Galton whistle or monochord for
all hearing tests.

Sir James Dundas-Grant asked whether members had been able to confirm the
diagnostic point described by Jones in his work on equilibrium and vertigo as an indica¬
tion of auditory nerve tumour. Jones said that on the same side as the tumour all the
caloric tests were negative, i.e., for the vertical as well as for the horizontal canals, and
that on the sound side the reflex from the horizontal canal was positive, but for the
vertical canals negative. He (Sir James) had shown before this Section a specimen from
a case in which these signs had been quite distinct: a tumour was found distending the
internal auditory meatus. The supposition was that the strands from the vertical
canal ran upwards near the middle line for some distance farther than those which
crossed to the horizontal canal; therefore the tumour transmitted the pressure through
the brain to the strands going to the vertical canals of the sound side; these were so
close to the middle line as to be involved, while the strands to the horizontal canal
escaped. Much of the testing could be carried out by means of the “ cold air *’
apparatus with little disturbance of the patient; he could rest in bed with his head on
a low pillow for the horizontal canals, and could sit up for the vertical canals. The
galvanic tests were of enormous value, especially when those for the labyrinth were
negative. In the case of an auditory nerve tumour, the galvanic test became negative
as well as the caloric.

Dr. Walshe (in reply) said he had expressed the opinion that we were
apt to have unduly precise notions as to the typical clinical picture of eighth nerve
tumours, and it was not surprising, therefore, that in the* course of his exceptional
experience Dr. Holmes had observed cases not presenting the usual clinical picture.
Nevertheless, he believed that the symptom-complex he had described was the most
typical, though there was really no disagreement between Dr. Holmes and himself on
the general question.

Section of ©tologp.

President—Sir Charles A. Ballanck, K.C.M.G., ('.B., M.V.O.

The Morbid Anatomy and Drainage of Otitic Meningitis.
By E. D. D. Davis, F.R.C.S.

These observations which I shall describe were limited to otitic meningitis
ofjthe base of the skull and were made from thirteen autopsies, of which there
are full notes, and from a number of specimens seen in the museums of the
London medical schools. Otitic meningitis of the middle fossa and cortex of
the brain was much less frequent than that of the posterior fossa and was
usually secondary to a temporo-sphenoidal abscess, or a localized meningitis
occurred. In the autopsies mentioned above, thick gelatinous pus was
invariably found in the cisterna interpeduncularis from which it extended into
the subarachnoid space taking the path of the large cerebral vessels. In front,
the pus spread over the optic chiasma and along the anterior cerebral artery to
the longitudinal fissure, forming a collection of pus above the corpus callosum.
In the later stages the pus travelled on each side along the middle cerebral
arteries and Sylvian fissures to creep up the cerebral cortex. More frequently
suppuration extended backwards by the posterior cerebral arteries and around
the crura to form an abscess between the tentorium and the superior surface of
the cerebellum.

The cisterna magna, or cisterna cerebello-medullaris, was free from pus in
some cases, but in the late stages and when suppuration was advanced, pus
extended backwards, surrounding the medulla and reaching the cisterna magna
by that route. Collections of pus were present (l) at the internal auditory
meatus and on the posterior surface of the petrous bone immediately in front
of the lateral sinus; (2) in the cisterna interpeduncularis; (3) between the
tentorium and the superior surface of the cerebellum ; (4) in the longitudinal
fissure above the corpus callosum.

The path of infection in seven cases was traced through the fenestra ovalis
to the labyrinth and to the internal auditory meatus, then to the under surface
of the pons and the cisterna interpeduncularis.

In one case there was thrombosis of the lateral sinus, with a collection of
pus round the sinus and covering the under surface and posterior aspect of the
cerebellar hemisphere.

In one other case, a collection of pus was found in the aqueduct of the vesti¬
bule and it appeared to reach that position along the saccus endolvmphaticus.
Fistulae of the external semicircular canal or of the promontory were not
discovered. In the remaining four cases the path of infection was untraceable
and may have been part of a blood infection or septicaemia.

In order to demonstrate the paths of infection, a series of experiments
^ere carried out on the cadaver, in which the subarachnoid space was injected

[April 20, 1923.

44 Davis: Morbid Anatomy and Drainage of Otitic Meningitis

with a solution of methylene blue run by a funnel and tube through the internal
ear and internal auditory meatus, and at a subsequent examination, when the
skull cap and brain were removed, the methylene blue was in every case found
in the cisterna interpeduncularis extending to the optic chiasma and backwards
around the crura to the interval between the tentorium and the cerebellum, but
no methylene blue was present in the cisterna magna or in the ventricles.
Similarly when the injection was made through the dura mater immediately
in front of the lateral sinus (to resemble infection by sinus phlebitis) the
pigment was limited to the under surface and posterior aspect of the cerebellum
extending to the incisura posterior and to the cisterna magna; none was seen
in the other cistern®.

These experiments were adapted to test the various routes of drainage and
30 c.c. of methylene blue were injected through the internal auditory meatus
to the cisterna interpeduncularis; practically all the 30 c.c. of pigment were
recovered by aspiration through the same channel with a coarse needle and
syringe. When a trocar and cannula were inserted through the atlanto-
occipital ligament and foramen magnum, to tap the cisterna magna, no pigment
drained away.

Again, when 30 c.c. of blue were injected in front of the lateral sinus, only
2 c.c. were recovered by aspiration, but occipito-atlantal puncture of the
cisterna magna produced drops of the blue fluid.

Lastly, during and after the injection of methylene blue through the internal
auditory meatus, a cannula was inserted in the spinal theca in the lumbar
region and it was surprising to notice that no methylene blue came through,
not even when 10 c.c. of cerebro-spinal fluid were drawn off and considerable
suction was employed by a syringe. Also, later examination of the brain
showed no appreciable diffusion of the pigment beyond the cisterna interpedun¬
cularis. These facts point to two conclusions; first, that repeated lumbar
puncture during life does not increase the area of suppuration, and, secondly,
that lumbar puncture is inefficient as a method of drainage.

Although these experiments are artificial and it cannot be claimed that they
reproduce exactly the phenomena of meningitis during life, yet when they are
considered in conjunction with the morbid anatomy, the following conclusions
may be justified :—

(1) When meningitis is so far advanced that the cisterna interpeduncularis
contains pus, or in the still later stage when there is pus in the cisterna magna,
efficient drainage is obviously difficult. Therefore the prospect of saving patients
in cases of meningitis is very much improved by the earliest possible
diagnosis, when the suppuration is limited to the labyrinth or lateral sinus
area, or, at the latest, when the suppuration is localized to the area around the
internal auditory meatus and posterior surface of the petrous bone. When the
infection arises from sinus phlebitis the prognosis is probably better than when
it spreads through the internal ear, because in the first case the suppuration is
more usually localized to the posterior fossa and may not extend to the
cisterna interpeduncularis.

(2) When meningitis arises from infection of the labyrinth, drainage and
suction by a syringe through the internal auditory meatus are least inefficient
and most likely to be successful.

(3) If meningitis arises from sinus phlebitis, drainage and suction should
be effected both behind and in front of the lateral sinus, and in this type of
case occipito-atlantal puncture may be useful.

(4) Lumbar puncture is not a satisfactory method of drainage for pus, and

Section of Otology

4 5

though it is recognized as a valuable aid to treatment, Weed, Wegeforth, Ayer,
and Felton, of the Rockefeller Institute, have conclusively shown by a series of
experiments and controls that if a bacteraemia or septicaemia is produced by the
intravenous inoculation of the Bacillus lactis a'crogenes or other organisms, in
animals, a fatal meningitis is established by lumbar puncture or by the with¬
drawal of cerebro-spinal fluid, whereas meningitis does not occur in those
septicaemic animals in which cerebro-spinal fluid is not withdrawn. The
importance of these experiments is accentuated by the fact that meningitis i&
sometimes due to a blood infection and the above observers have proved that
animals dying of meningitis seldom fail to show organisms in the blood-vessels
either microscopically or culturally. Blood infection is almost invariably
present if meningitis has existed for eighteen hours and septicaemia probably
plays an important part in the death of the animal suffering from meningitis.
Further experiments strongly indicated that facilitation of the involvement of
the meninges from the blood stream after removal of cerebro-spinal fluid is
dependent upon the reduction of the pressure of the fluid or on other general
intracranial reaction, even if such reduction is of very short duration, and is
not related to the injury produced by the needle. The immediate replacement
of the cerebro-spinal fluid by Ringer’s solution does not prevent the onset of
meningitis, and it is thought that fluid leaks into the tissues through the
puncture ; this leakage could be diminished by using a fine needle, and incident¬
ally prevent “ lumbar puncture headaches.”

This excellent work from the Rockefeller Institute supports Jenkins’ state¬
ment that only the smallest quantity of cerebro-spinal fluid—sufficient, i.e., for
diagnosis—should be withdrawn by lumbar puncture.

REFERENCE.

Weed, Wegeforth, Ayer, and Felton, “ A Study of Experimental Meningitis,” Monographs
of the Rockefeller Institute for Medical Research , No. 12, March 25, 1920.

DISCUSSION.

Sir CHARLES Ballance (President) said that Mr. Davis’s paper was the kind of
communication from which much could be gleaned. There was always an inclination
to publish cases which were successful, but much more could be learned from a post¬
mortem examination of failures.

Mr. SOMERVILLE Hastings asked what Mr. Davis considered to be the clinical
indications for occipito-atlantal puncture. He, himself, had never done it, and he
would be glad to hear what was its technique.

Mr. J. F. O’Malley asked what symptoms would induce Mr. Davis to open directly
through the labyrinth, or to put in a drain in the wall of the antrum in front of the
lateral sinus. Or did he think it an advantage to do both at the same time ?

Mr. T. B. LAYTON said he was interested to hear that there was some danger in
doing lumbar puncture. He used to imagine that it was a small operation which could
not do any harm, and therefore in any case of doubt should be carried out to help the
diagnosis. Mr. Davis’s paper seemed to show that although it might be undertaken in
order to obtain further evidence when necessary, there were cases in which the question
should be carefully considered. He asked whether, in either of Mr. Davis’s cases
w hich were successful, organisms were found in the cerebro-spinal fluid. Information
w as needed as to what was the kind of case in which drainage of the cerebro-spinal
cavity in the hope of saving the patient’s life was advisable, as distinct from cases in
which removal of the infected bone in relation with the dura was all that was
necessary.

46 Davis: Morbid Anatomy and Drainage of Otitic Meningitis

Sir CHARLES BALLANCE (President) said this was an extremely important subject,
as the treatment of these cases was a matter of life and death. Mr. Layton had
referred to lumbar puncture; he (the President) had known sudden death occur from
lumbar puncture, which should never be done without careful consideration in certain
cases, because it produced a change in the position of the cerebellum, and affected tin-
vital centres in the medulla. Another important question mentioned by Mr. Layton
was as to whether organisms were present or not. Frequently, in past years, he (the
President) had done lumbar puncture and had found turbid fluid ; and he thought there
was no question that organisms had been present, but the reports frequently stated
that the milky condition of the fluid was due simply to the cells, since no organisms
could be cultivated from it. If no organisms were in the fluid, and the proper treat¬
ment were earned out, the patient would, almost certainly,*recover. But if organisms
were present, the difficulty of saving the patient was likely to be very great indeed.
In the fulminating cases of meningitis the patient might die within thirty hours of the
onset. In such cases the outlook was at present hopeless, though the attempt to save
life should not be abandoned. He had been interested in Mr. Davis’s remark about
methylene-blue injections into the subarachnoid space. During the war, he (the
President) had found that washing out the subarachnoid space in cases of meningitis
from the lateral ventricle, putting the puncture-needle into the lumbar theca, and
colouring the salt solution with methylene-blue caused the blue fluid to come out of the
lumbar puncture cannula in twenty-five seconds. It was therefore extraordinary to
hear now that in a dead body the fluid obtained by lumbar puncture was not coloured
by the methylene-blue, which had been injected definitely into the subarachnoid space
of the cranial cavity. There was no doubt, as Mr. Davis had said, that the only
possible treatment of these cases was by operation, and that the surgeon should be able
to operate within a very short time of what he believed to be the onset of meningitis.
That, however, was very difficult to ensure, because the usual experience was that
patients in these cases were not seen until they were practically moribund. At first
the symptoms were slight, but later unconsciousness supervened, and the surgeon was
called in in the hope of saving life when that had become impossible. The course of
the cerebro-spinal fluid in health was well known, and in the living body the fluid
carried coloured material rapidly in various directions. In Golla’s experiments on the
cat, injections into the lumbar theca spread rapidly almost everywhere. It was known,
also, that the fluid was secreted by the choroid plexuses, and came out of the ventricles
through the openings in the roof of the fourth ventricle, spreading into the great cisterna
at the back of the under surface of the cerebellum, and then travelling forward into the
interpeduncular space and various cisternse at the base of the brain. It also flowed
down the spinal canal. It then spread, as Mr. Davis described, over the surface of the
hemispheres in the direction of the superior longitudinal sinus, especially in the region
of the Sylvian fissure. Probably some members had seen the spread of this rapidly
fulminating subarachnoid meningitis; he had watched it on the operating table; the
greenish pus underneath the subarachnoid membrane spreading from sulcus to sulcus
between the convolutions. Everyone wished to know how this process could be
arrested. He (the President) disagreed with Mr. Davis on one point—namely, that
occipito-atlantal puncture was a surgical operation which should replace drainage. To
his (Sir Charles Ballance’s) mind, such a view was reactionary, in the sense that none
of them would now think of treating an acute abscess in any other position by
means of puncture with trochar and cannula. Occipito-atlantal puncture was easy to
do, and there was no danger in it, unless the operator was in doubt of his ability to
perform it. But he felt strongly, from what he had seen post mortem in meningitis
cases, that no puncture was capable of arresting the process which was spreading in
the subarachnoid space. If the condition was due to infective organisms, he (Sir
Charles) thought the only possible surgical way of dealing with it was by Haynes'
method. If the stream of fluid could only be directed out through a surgical opening
in the great cerebellar cistern, its spread in the other directions might possibly be
arrested. He had always been much impressed with the fact that meningitis and other
infections in the skull were greatly enforced by increased pressure. If the pressure of
the fluid in the subarachnoid space were reduced, he believed there would be a good

Section of Otology

•chance of preventing the further spread of the infection. If, then, by opening the great
cerebellar cistern, one could diminish the pressure of the fluid in the subarachnoid
space, and start the current of fluid in a new direction, the hope of stopping the
spread of inflammation over the brain surface might be entertained. But as matters
stood at present one could not expect to cure all these cases. He thought, however,
that the condition should be treated as an acute suppuration in any other part of the
body was treated.

Mr. E. D. I). Davis (in reply) said that the method adopted for occipito-atlantal
puncture was as follows: The head must be slightly flexed and the needle inserted at a
point in the mid-line of the neck immediately above the spine of the axis and directed
in the mid-line to the fronto-nasal suture. The needle would be felt to go through the
occipito-atlantal ligament with a jerk ; then it was necessary to move carefully and to
see that the direction to the fronto-nasal suture was correct. The operation could be
done without an anaesthetic. It was now frequently performed without mishap.
He (Mr. Davis) thought that occipito-atlantal puncture might be sometimes more
useful than Haynes’ operation. He considered that the eisterna magna contained pus
only in the very late stages of meningitis, hence Haynes’ operation was generally
unsuccessful at so late a stage of meningitis. Occipito-atlantal puncture was valuable in
cases in which the patients were more or less moribund, and in which the surgeon felt
impelled to do something. In reply to Mr. O’Malley’s question as to when to drain
through the labyrinth, Mr. Davis said that if it was decided that the meningitis had
arisen from labyrinthitis—that is, when the signs of labyrinthitis had preceded the
meningitis—drainage should be established through the internal auditory meatus and
the labyrinth. He admitted that it was sometimes difficult to decide on labyrinthine
drainage in suspected meningitis when the diagnosis was uncertain, as it required some
courage to go through the labyrinth and destroy the internal ear. But if there Were
indications that meningitis had reached the skull through the labyrinth, then drainage
through the internal auditory meatus must be done. When meningitis arose from
lateral sinus thrombosis or infection, he (the speaker) left the labyrinth alone and
drained in front and behind the lateral sinus. One of the two cases he had mentioned,
was that of a patient whom he had shown at a former meeting of this Section. 1 She
had all the symptoms of meningitis—headache, vomiting, drowsiness, and the cerebro¬
spinal fluid gave pneumococcus on culture. He had operated practically as soon as he
saw her. There was a large extradural abscess between the posterior surface of the
petrous bone and the dura, arising from a perisinus abscess which tracked forward
between the dura mater and the petrous bone ; he had drained this and had left the
wound open so that later if there was no improvement, he could drain through
the dura mater. The patient had done well for a few days, but then she had become
more drowsy and vomiting had recommenced. He (Mr. Davis) therefore drained the
subarachnoid space in front and behind the lateral sinus and the patient recovered.
He thought it was a localized meningitis of the posterior fossa. In the other case, the
patient had had an acute attack of suppuration sometime after a radical mastoid operation
performed elsewhere. There had been a temperature of 103° E. and signs of meningitis,
therefore the mastoid had been opened up again and the posterior fossa drained behind
the lateral sinus. The cerebro-spinal fluid had contained pneumococci. The patient
had done well.

The cases recorded by Mr. Lawson Whale 2 and Mr. Martvn* appeared to have been
similar to these tw r o cases.

Case of Complete Deafness dating from a Fall.

By Sir James Dundas-Grant, K.B.E., M.D.

PATIENT, male, aged 48, became completely deaf about three and a
half years ago, after a fall of 6 ft. on to his feet, not striking his head but
suffering pain in his neck several days later. He felt ill and had to be helped

1 Proceedings , 1922, xv (Sect. Otol.), p. 44.

- Brit. Med. Jo urn., February 24. 1923, p. 323.

* ' Lancet , March 10, 1923, p. IH.V

48 Dundas-Grrant: Deafness greatly increased after a Fall

home. During the night he had diarrhoea and vomiting and next morning was
quite deaf. He was told that he shouted when speaking. Dr. Dan McKenzie
referred him to me at the West End Hospital for Nervous Diseases, for
consideration of neurological possibilities. My colleague, Dr. Carlill, kindly
took the greatest interest in the case and gave it the benefit of treatment by
gross suggestion. The result was negative and in favour of an organic lesion.
The anomalous character of the data has rendered the diagnosis difficult.

On examination in May, 1922, when he appeared to be totally deaf for
sounds of any kind, and there being then no voice-raising with noise-machines
in the ears, the click of the large “ distinette ” produced a palpebral reflex.
There was marked spontaneous nystagmus to the left and slight past¬
pointing to the right ; the voice was monotonous. Lip-reading had not been
spontaneously acquired. Rotation to the right with external canals horizontal
produced no increase of nystagmus to the left. Rotation to the left produced
active nystagmus to the right but no past-pointing. Cold air to the right
external canal caused nystagmus in thirty-five seconds. Cold air to the left
external canal produced no nystagmus after sixty seconds. Cold air to the
right vertical canal caused slight rotary nystagmus to the left. Cold air to the
left vertical canal obtained no response. Past-pointing and giddiness were not
induced by any of these tests. Galvanism (tested in November) on either side
with 15 ma. excited nystagmus in the direction of the cathode.

These tests suggest a lesion—concussion—of both labyrinths, the auditory
nerve trunk being unimpaired. The left labyrinth appeared to be the most
affected, yet the spontaneous nystagmus was to the left side.

The symptoms varied slightly from time to time, so as to suggest a
functional element in the case, as also did the diminution of the pharyngeal
reflex.

Case of Deafness greatly increased after a Fall.

By Sir James Dundas-Grant, K.B.E., M.D.

PATIENT, female, aged 29, had been dull of hearing for nine or ten years, but
became extremely deaf ten months ago after a fall of 25 ft., in which her head
was knocked and after which she was unconscious for seven or eight days.
When first seen in September, 1922, she heard whispered voice at only 12 in.
on the right side and 2 in. on the left, reduced by inflation to 6 in. and h in.
respectively. On the other hand the ordinary voice heard at 14 in. and 4 in. was
after inflation heard at 3 ft. and 2 ft. respectively. The hearing for Gradenigo’s
tuning-fork (64 d.v.) was reduced considerably, viz., to 3 and 2 instead of 6.
Bonnier’s test (tuning-fork 128 d.v. heard through condyles of femur) was
positive. Paracusis Willisii was present. Bone-conduction on the mastoid
was normal and Rinne was markedly negative. Weber positive. Galton's
whistle normal (l’l). The Eustachian tubes were slightly narrow. The
features were essentially those of otosclerosis, but there was no family
tendency and there w 7 as no initial tinnitus.

She was treated by occasional inflation and frequent self-inflation while
at the same time she took, with small doses of ignatia amara, 5 minims of
liq. hydrarg. perchlor., thrice daily. This last remedy w T as given because
of Erichsen’s use of it in the treatment of “ railway spine ” concussion, to
which the traumatic condition in the present case seemed analogous. In
October she reported herself as feeling better in herself and freer from tinnitus.
At present she seems to have reached a stationary condition and states that
she hears as well as she did before the accident.

Section of Otology

The nature of the change induced by the accident is to some extent
a matter of conjecture. It may have been either functional or organic.
The history supplies sufficient ground for either or both. Opinions will be
welcome.

Case of Long-standing Deafness attributable to Falls on
the Head ; Improvement.

By Sir James Dundas-Grant, K.B.E., M.D.

PATIENT, male, aged 25, with deafness of fifteen years' duration, gave a
history of a fall when 10 years old, which was followed by giddiness and
commencing deafness.

First seen, October, 1921. Whispered voice heard at 5 in. right and 10 in.
left. Improvement on inflation to 12 in. right, but none on the left. C 64 d.v.
not heard. Tuning-fork by bone-conduction on vertex equal both sides and on
mastoids slightly increased; Rinne negative. C 128 d.v. heard by femur
condyle (Bonnier). Galton’s whistle reduced to mark 4 on the right and 3*2
on the left. Eustachian tubes narrow. Gell6 negative right, positive left.
Rombergism to right, nystagmus to left. Cold air labyrinth test, nystagmus
delayed; past-pointing normal.

The features are those of a nerve-deafness, probably cochlear, with
concomitant chronic Eustachian catarrh.

The patient is well-built (up till recently played football), cheerful in
disposition, but with a somewhat monotonous voice. There is a slight
asymmetry of the face. His deafness was so considerable that he was unable
to use the telephone, and his livelihood was in jeopardy. He was also so
unsteady and apprehensive that he had to be accompanied by his brother.

He was first treated by means of inflation (catheter, Politzer, &c.), and in
November reported improvement. His Eustachian tubes appeared to be more
pervious. Glycerophosphates and paraffin were ordered.

In January, 1922, whisper was on the right side 2 ft., improved by
inflation to 5 ft., and on the left 24 ft. improved to 7 ft. Galton (left) 4*6.
Induction of nystagmus still delayed.

In view of the traumatic factor small doses of liq. hydrarg. perchlor. were
ordered tentatively. In March his hearing for the whisper was on the right
side 3 ft. improved to 5 ft., and on the left 5 ft. improved to 20 ft. In
December the whisper on the right side was at 2 ft., improved to 4 ft., and on
the left 18 ft., improved to 18-j ft.

In February of this year he had an attack of influenza accompanied by
retrogression in his hearing-power, but I hope to find it is only temporary.
The improvement in general alertness and usefulness is unmistakable in what
at first appeared a most discouraging case.

He is to be examined by an ophthalmologist on account of defect of vision
ifl his right eye; the result may throw fresh light on his case.

DISCUSSION.

bir CHARLES Ballance (President) said that no surgeon objected to perehloride of
mercury being given to any patient, and in these particular instances the drug appeared
to have been useful.

Mr. F. J, Cl EM IN SOX said he had recently seen a man aged 29 who, while crossing
the Channel in a gale, was quietly sleeping in a saloon when a slab of marble.

50 Dundas-Grant: Long-standing Deafness attributable to Falls

weighing 1 cwt., fell on to his head, causing not only profound traumatic neurasthenia,
but considerable deafness in both ears, especially in the right. That had occurred
twelve months ago, and the patient had had treatment for some time, and had eventually
brought a suit against the railway company: it was in that connexion that he (Mr.
Cleminson) had seen him. The condition he had found was a marked deafness to both
the voice and acoumeter on the right side, and to a less degree on the left. A 30-in.
watch had been heard at 8 in. by the right ear, and at 16 in. by the left. When the
ears were syringed with cold water, there had been a delayed response on the right,
and the tests with the tuning-fork, &c., had pointed to internal ear deafness on that
side. He (Mr. Cleminson) was unable to visualize the lesion which occurred in such
cases; perhaps Sir James Dundas-Grant could suggest what happened. He haul only
seen the patient twice, at an interval, and he did not know what had happened to him
since the last occasion.

Mr. J. F. O’MALLEY said these cases often presented difficult problems, e.g., as to
why a patient should be seized with sudden deafness, apart from injury. A fortnight
ago, a woman engaged in selling newspapers in the street came to see him at the clinic,
accompanied by a friend who stated that the patient had been well until four days
previously, then deafness had suddenly occurred, and she had been unable to hear
anything since. There was no history of an accident or of vertigo which would suggest
a sudden lesion of the labyrinth, rupture of a blood-vessel, or an invasion of a syphilitic
nature. He (Mr. O’Malley) had had the patient’s vestibular reaction tested, and there
was a good response. In the case of a deaf and aphonic soldier whom he had seen
during the war, when, after producing a vigorous vestibular reaction with a cold
application, he had applied a speaking-tube, and shouted down it, he had obtained
a prompt answer. But he had obtained no answer from the patient in the case to
which he was now referring. Sir James Dundas-Grant’s second case seemed to him
(Mr. O’Malley) to be one of otosclerosis; but it would be difficult to explain how the
fall had increased the deafness, as the tests showed that bone conduction was good all
the time. He thought there was a large element of functional disturbance in that case.
In the third case he had noticed the peculiar voice—a manner of speaking associated
with deafness in early childhood; the patient learning to speak better as he grew older.
He (Mr. O’Malley) had found that kind of voice in cases in which the patient had had
an attack of cerebro-spinal meningitis in early life, but in which the hearing had not
been completely obliterated, and later difficulty had occurred in controlling the pitch of
the voice.

Mr. E. D. D. Davis said that during the war he had seen several cases of injury, in
the region of the mastoid process, in which the deafness was permanent. In the
commoner concussion case, such as that from a motor accident, the hearing really
did improve. If the hearing did not improve within six weeks after the accident,
he (Mr. Davis) considered that the deafness was likely to be permanent. He asked
whether one was justified in that conclusion. It was his experience that by deafness
occurring after a shell or bullet wound in the region of the mastoid process or posterior
fossa of the skull, without any direct injury to the ear itself, the loss of hearing was
usually permanent.

Sir James Dundas-Grant (in reply) said it was useful to remember the old
observation that when the handle of a broom was struck on the ground, the handle
was driven more deeply into the broom-head. A fall on the feet sometimes caused
fracture of the base of the skull, and there might be real damage to the delicate
structures in the internal ear even in the absence of skull fracture. He (Sir James
Dundas-Grant) believed that these injuries were often accompanied by fractures which
healed and left no trace, even on post-mortem examination years afterwards. He
thought that in some cases of injury of the head, at some distance from the ear, there
was a fracture through the internal ear, or at all events such a shaking up that the
internal ear was rendered insensitive, and it might be completely disorganized by
haemorrhage either into the labyrinth or the internal auditory meatus. He agreed with
Mr. Davis that if no improvement took place within six weeks, there had been
something more than a mere concussion and that destruction had occurred. But his
own experience in the third case showed that it was unwise to despair too soon.

Section of ©toloos.

President—Sir Charles A. Ballance, K.C.M.G., C.B., M.V.O., M.S.

An Instrument for Assisting the Deaf.

Exhibited by W. M. Mollison, M.Ch.

The instrument now exhibited is known as the Marconi Otophone. It
consists of electrical amplifying circuits in a polished cabinet to which are
connected a sensitive microphone and a pair of head telephones.

By means of three switches the amount of current supplied to the valves
can be regulated and the degree of speech amplification can be adjusted to five
different values.

The Marconi Company does not intend to market this instrument through
the usual trade channels, but proposes to supply it only through the recom¬
mendation of the medical profession. A full description can be obtained from
the Marconi Research Department.

DISCUSSION.

Mr. MOLLISON said that he had only had a week’s experience of the instrument,
but already he had found it useful in helping really deaf people to hear.

Sir Charles Ballance (President) said that this was a remarkable instrument.
In course of time it would no doubt be greatly improved; it would be a great advantage
if outside noises could be suppressed. A great obstacle to its use at present was its
weight (16 lb.).

Mr. SOMERVILLE Hastings asked whether the instrument had been tried in the
case of congenital deaf-mutes. When he (the speaker) heard the confusing extraneous
sounds, he wondered whether it would be possible to attach a funnel to the microphone
which could be directed towards the sound one desired to hear.

Epidemic Cerebro-spinal Meningitis associated with Acute
Suppuration of the Middle Ear.

By Frederick Sydenham, F.K.C.S., and Dan McKenzie, M.D.

The patient, a girl, aged 16, was admitted to hospital under Mr. Sydenham’s
care in February, 1922. She was semi-comatose and, to all appearance, totally
deaf; the temperature was 103*5° F.; there was discharge from both ears with
pain in both mastoids, and oedema on one side. The Heath operation was
performed on both sides. A little pus was found in the antrum, but nothing
further, and not enough in Mr. Sydenham’s opinion to account for the grave
Au— Ot 1 [May 18, 1923.

52 Sydenham & McKenzie : Epidemic Cerebrospinal Meningitis

symptoms. Both lateral sinuses were exposed and explored. The patient
made a good recovery but remained deaf.

On December 7, 1922, she came under the care of Dr. McKenzie, on
account of the deafness. On examination she was found to hear all the
tuning-forks, but only for a few seconds, both by air and bone. A shout was
heard as a loud noise only. The caloric tests were negative.

The case is reported as one of (probable) epidemic meningitis associated
with suppuration of the middle ear, to draw attention to the possibility of the
meningeal infection being due to that of the middle ear (see Journal of
Laryngology , 1922).

Epileptiform Seizures subsequent to Operation for
Temporo-Sphenoidal Abscess.

By Dan McKenzie, M.D.

The patient, a woman aged 35, was operated on for temporo-sphenoidal abscess
six years ago, the pus being successfully evacuated through the antro-tympanic
roof. The abscess was chronic, symptoms having existed for about six months,
and the walls of the cavity were thick and tough. The first suspicious seizure
occurred a year after the operation, and they are becoming more frequent as
time goes on. But they have never amounted to more than one in two or three
months. The diagnosis of probable epilepsy has been made by Dr. C. O.
Hawthorne.

DISCUSSION.

Sir Charles Ballance (President) said that the second case seemed to be an
unusual one, because the temporo-sphenoidal abscess was followed—a long time
afterwards—by epilepsy; he (Sir Charles) did not remember that sequence in any of
his own cases, though epilepsy following brain operations was not infrequent. In the
first case, he supposed there must have been, as suggested, some meningitis in
the posterior fossa, which involved the nerve, and consequently when the patient
recovered she was deaf. He remembered one case of pterygo-maxillary abscess in a
case which was complicated by some intracranial infection; he believed it was lateral •
sinus infection. In his experience successive operations were always unsatisfactory,
and often ended fatally. Whenever it was possible, all that was needed should be done
at one operation. In this case the cavernous sinus was thrombosed, and there had
been no attempt to deal with that infective process. He asked whether there had been
a recent operation on infective cavernous thrombosis, and if so, what had been the
result. Had any member had a successful operation recently ?

Sir James Dtjndas-Grant asked whether in the second case there was any
localizing Jacksonian sign or any warning aura in connexion with the epilepsy.

Mr. E. Musgrave Woodman said he had asked the patient whether she had any
such warnings and she had told him that she suddenly fell down wherever she happened
to be. This seemed to him significant, and suggested that the condition might be
hysterical. It would be interesting to hear from members their views as to what
treatment, operative or non-operative, would suit such a case, especially if the seizures
were caused by a brain scar.

Dr. Dan McKenzie (in reply) said that he had since seen another case, in a patient
who had undergone an operation twenty years ago. There had first been a brain
abscess, which was operated upon by Mr. Marsh, of Birmingham; then a mastoid
operation had been performed by Sir Charles Ballance. He (Dr. McKenzie) had not

Section of Otology

been able to persuade the man to come to the meeting. The attacks seemed to be those
of petit mal or automatism. The patient had never had regular epileptic convulsions.
He (the speaker) did not know whether in the present patient it would be worth while
to try and reopen the old area. Mr. Tilley had told him of a case—in his own practice—
of epilepsy following brain abscess in which operation had been successful, i.e., there
were no fita following it. The epilepsy in these cases might be idiopathic, and then
operation would be useless. If the fits were due to a scar, conceivably operation would
bring relief.

Sir Charles Ballance (President) referred to a patient who, before suffering from
a left temporo-sphenoidal abscess, was very musical, but afterwards lost his musical
sense and was unable to play the piano. With regard to operation in cases of petit mal ,
or so-called idiopathic epilepsy, he (the President) had seen many of these cases during
and after the War; he thought the scars in the brain produced a definite vascular
change in the cortex. When exposing the cortex, he had seen a blush come round the
scar and the area then became white again. If the scar w r as adherent to the dura, and
the dura adherent to the bone, the normal excursions of the brain were prevented,
and in such a case, he thought, some benefit would be produced by freeing the dura and
thus allowing the brain to move freely again. In some cases in which he had carried
out this plan the epilepsy had ceased, but he did not think he had done so after
operations on brain abscess caused by ear disease. A, drug which he had used in war
cases with remarkable effect was luminal; if a patient takes this drug continuously in
small doses, the epilepsy may not return. To prevent the parts becoming adherent,
Mr. Sargent used celluloid, which served the purpose very well as, like pure platinum,
it was not acted on by the tissues and fluids of the body.

Otitic Pterygo-maxillary Abscess induced by Thrombo¬
phlebitis of the Jugular Bulb.

By Dan McKenzie, M.D.

A boy, aged 8, was admitted to the Central London Throat and Ear Hospital
with chronic suppuration of the left middle ear and a temperature of 102° F.
Immediate radical mastoid. No relief to temperature. Two days later wound
re-opened, and a small drop of pus on the floor of the external meatus was
found to lead to an abscess in front of the bony meatus. This was opened and
drained, and a counter opening made into the pharynx. Lateral sinus ex¬
plored, no clot found. No relief to temperature. Two days later, internal
jugular vein exposed and resected. Thrombosed down to lower border of
thyroid cartilage. Vein cleared of clot with curette as high as jugular bulb.
Next day signs of cavernous sinus thrombosis, followed two days later by
death.

Post-mortem .—Specimen (on view) shows erosion of outer wall of jugular
bulb leading to the site of abscess in the pterygo-maxillary fossa. No evidence
of bone disease adjacent to the abscess.

This was evidently a case of thrombosis of the jugular bulb, which had ex¬
tended down the vein into the neck, but not upwards into the lateral sinus.
The thrombus in the bulb had broken down, and the pus had made its way
through the wall of the bulb into the pterygo-maxillary fossa, tracking down
towards the pharynx, and back over the floor of the external meatus. This
development is rare. Going over the literature of pterygo-maxillary abscess
in 1915,1 could find only three cases in which the abscess was (doubtfully)
traceable to thrombosis in the bulb.

Just: Brain Abscess due to Otitic Infection

Brain Abscess due to Otitic Infection; Right Temporo-
sphenoidal Abscess without Clinical Signs.

By T. H. Just, F.R.C.S.

E. A. M., AGED 27, had had otorrhcea and deafness; right side, since child¬
hood. She had had no other symptoms until a few days before admission to
St. Bartholomew's Hospital early last year, when she had had constant
headache for three days, increasing in severity, and each morning she had
vomited.

Condition on admission: Was able to walk slowly, but kept her head still,
and there was some rigidity of the neck. The temperature was 101‘2 F.,
pulse 120. The right tympanic membrane was obscured by epithelial d6bris,
purulent discharge, and granulations. No abnormal signs were discovered
during the examination of the central nervous system. The patient was right
handed. There was no amnesia.

I decided to explore the right mastoid and expose the dura mater.
Accordingly the radical operation was performed. The mastoid was acellular,
but the roof of the antrum was carious and an extradural abscess was found
immediately above the tegmen.

The dura mater beneath the temporo-sphenoidal lobe was covered with
granulations; no pulsation of the brain could be felt; in the centre of the
exposed dura mater a sinus was found leading into an abscess within the brain.
This was opened up and drained by tubes. In draining the abscess I used the
procedure which Harvey Cushing suggested in the treatment of war wounds.
With a No. 10 catheter I washed out the cavity with saline solution and
sucked out the material used in washing-out, repeating the process several
times in the effort to get away all the debris from the abscess cavity; I did
that until the saline returned clear. The tube was kept in ten days; at the
end of which time there was no pus coming from the abscess cavity, therefore
I left the tube out. In a recent case in which the wound is not yet healed, I
used the same technique. In this case there was li oz. of offensive pus in the
temporo-sphenoidal lobe; I took away the granulating dura which was covering
the abscess, and washed and sucked it out with a syringe for ten minutes, I
then put in a tube, and shifted the tube on the second day when no pus came
out, but only a little straw-coloured fluid. On the third day I removed the
tube altogether. In war wounds of the brain it was found better to keep the
tract clean and not to use a tube, as the tube seemed to act as an irritant.
Recovery was progressive and uneventful, and she left the hospital five weeks
afterwards.

It is now nearly eighteen months since this operation, and nothing
further has developed, though she occasionally attends the out-patient depart¬
ment complaining of vague “ sensations down the right side of the body,"
which my neurological colleagues regard as “ functional."

DISCUSSION.

Mr. G. J. Jenkins said that it was difficult to generalize as no two cases of these
abscesses quite followed the same course. In one of his own cases he had drained with
corrugated rubber tissue; this tissue was much softer than a drainage tube, and as
much or as little as required could be packed into the cavity. Sometimes a tube was

Section of Otology

rendered useless by becoming blocked. His (the speaker’s) inclination was to make
the drainage from the abscess-cavity as free as possible, cutting away a good deal of
the wall, according to the extent of the surrounding adhesions. This plan was likely
to be much more effective than that of making a small hole and passing a tube
through it.

Dr. W. Kelson asked whether the abscess was chronic or acute.

Sir James Dundas-Grant asked whether there was any objection to exploring the
abscess cavity with the protected little finger, so as to ascertain whether the abscess
wall was rigid, and whether there was, possibly, a second abscess feeling like an oyster
through the wall. If the wall was not dense, the case would be suitable for removal of
the tube, whereas if the wall was dense, it would be most unsuitable.

Sir Charles Ballance (President) said that, except in a few cases, he had never
dealt with a brain abscess without drainage, the exceptions being those cases in which
he could enucleate the abscess. In his experience, a brain abscess was very difficult to-
drain. The liquid tissue of the brain was the difficulty. If the abscess had no wall,
then as soon as pus came out, the brain flowed around and filled up the cavity. If one
took out the drainage tube to see how the case was getting on, it might be very
difficult to replace it accurately. His (the speaker’s) best cases had been those in
which he had inserted the drainage tube immediately after opening the abscess, and
left it there. The suggestion to use rubber tissue might be a good one. It was difficult-
to wash out brain abscesses ; the size of them was not known, so that sometimes the
attempt to wash them out was dangerous as well as difficult. Moreover, sometimes-
a brain abscess had diverticula, and when the main abscess was drained, the pus in
these diverticula was untouched. Brain abscess cases certainly required much caution
in their management.

Mr. Just (in reply) said that he realized the difficulties and limitations in dealing
with brain abscess, but he thought what he had done was worth trying. In reply to
Dr. Kelson, he said that the abscess was sub-acute and that the walls were not very
thick. He had used rubber tissue instead of a tube, and, on the whole, he preferred it*

Left Temporo-sphenoidal Abscess; Amnesia for Names

of Objects.

By Sydney Scott, M.S.

F. N., AGED 10, was said to have had deafness in the left ear, for fully twe
years. She had been treated for otorrhoea until nine months ago, when the
discharge ceased, after removal of tonsils and adenoids. There had been no-
other symptoms until about a month before admission. She attended the
out-patient department complaining of pain in her left ear, and some otorrhoea,
but her condition was not regarded as serious until she had some kind of con¬
vulsion, followed by another two days later, and was then admitted as an
emergency case into St. Bartholomew’s Hospital. The convulsions were said
to have involved the right side of the face and right upper and lower
extremities.

Condition on admission : Conscious ; no hemiplegia. Temperature 101’6°F.,
pulse 96 ; tongue thickly furred. Some pus and d6bris in left external auditory
meatus. No mastoid signs, but slight tenderness left side. The knee-jerks-
were unobtainable. The superficial abdominal reflexes were weakened on the
right side. The child said she had no headache, but she liked to be left alone.
On being questioned to test her memory for names of objects she soon made
repeated mistakes, became confused, and exclaimed she “ could not be bothered

56 Scott: Left Temporo-sphenoidal Abscess ; Cerebellar Abscess

to think.’* Ifc seemed probable that the child had localized encephalitis of the
left temporo-sphenoidal lobe and I decided to open the mastoid at once and
expose the brain. The antrum and aditus contained cholesteatoma and pus,
and there was an extradural abscess in the middle cranial fossa, as in the preced¬
ing case. No pulsation of the exposed dura could be felt. When the dura was
incised unmistakeable adhesions to the arachnoid and pia mater were found,
extending to the lateral surface of the temporo-sphenoidal lobe. Nc pus escaped
through the dura, though the incision was carried into the cortex, nor did the
brain tissue protrude.

The child’s general condition did not become quite satisfactory, though
neurological examinations revealed no fresh signs: she was allowed up and
walked in the ward. The nurses said she seemed peevish and irritable and
behaved like a spoilt child, and her mother said she was unlike her real self.
In the third week she vomited unexpectedly two or three times. The “ name
amnesia ” persisted, and it seemed justifiable to make a more determined
exploration of the brain. I turned down a flap of the scalp and again exposed
the dura mater. On making an incision through the adherent membranes
into the brain I at once found the abscess. This was drained with rubber tubes,
and the child’s condition, temperament and memory rapidly improved
forthwith.

It is now one and a quarter years since this operation, and the child is
now particularly bright and well, though the period of convalescence cannot
be said to have been free from anxiety. Last summer she had more convul¬
sions after a minor plastic operation, and terrifying dreams frequently disturbed
her, night after night. No further operation on the brain has been necessary.
The operation cavity closed down and the meatus became stenosed. At present
a post-auricular sinus persists. Attempts to re-establish a meatus and to close
the sinus have been deferred until the child’s condition justifies the procedure.

The observation of amnesia for names of objects, the occurrence of
vomiting and absence of headache, were the leading clinical features of her case.
The presence of the extradural abscess and of adhesions between the dura and
the brain indicated the path of infection. Recovery was, no doubt, greatly
favoured by the dural adhesions.

Cerebellar Abscess; Sudden Coma and Apnoea; Recovery
after Operation during Artificial Respiration.

By Sydney Scott, M.S.

W. C. J., A YOUNG man, aged 17, was sent to London by his doctor, suffering
from severe headache and chronic otorrhcea. He was admitted to St. Bartholo¬
mew’s Hospital about 2 a.m., and in spite of his pain he could then walk and
stand, and showed no discernible physical signs apart from discharge from the
right ear. The house-surgeon withdrew some clear cerebro-spinal fluid,
obviously under pressure, and arrangements were made to operate on the ear
at 2 p.m. the same day. The patient became drowsy shortly before the time
for operation, and had become quite unconscious when I first saw him in the
operating theatre. Apart from confirming the evidence of middle-ear suppura¬
tion, and finding that the patient’s upper extremities remained elevated when
raised and left free (cataleptic state), no other observations could be made. An

Section of Otology

anesthetic was given, though this hardly seemed necessary, and the opera¬
tion on the mastoid was begun, but before the antrum had been opened the
patient had ceased to breathe. Artificial respiration was applied, and the
operation stopped, but breathing remained suspended while the dura mater
of middle and posterior cranial fossae were exposed. The tension of the dura
mater was much higher in the posterior fossa, and no pulsation could be felt.
No extradural abscess was seen. It was not possible, under the circumstances,
to see if any path of infection could be followed up, and the dura mater was
incised posteriorly to the sigmoid sinus, several radiating incisions through the
dura mater covering the lateral and inferior surface of the cerebellum. Here
no adhesions were encountered, the cerebellum prolapsed freely, expanding over
the edges of the cut dura mater. In the cerebellum a large abscess was found,
and on the escape of an ounce or two of pus spontaneous respiration was
resumed. It was, however, necessary to apply artificial respiration for some
little time, and the patient remained comatose for about two days, then he began
to recover, and it was possible by the usual tests to recognize the signs of a cere¬
bellar lesion, e.g., coarse nystagmus to the side of the lesion—asynergia and
unusual signs of co-ordination in limbs on same side as the lesion.

When he left the hospital after three months, he appeared to be perfectly
well.

It is remarked that the drainage in this case was not by the route of
infection for reasons which are obvious.

Cerebellar Abscess Five Weeks after Onset of Acute Otitis

Media, Right Side.

By Sydney Scott, M.S.

A BOY, aged 7, was admitted with otorrhcea and deafness on the right side.
During the previous week drowsiness had been noticed and he had vomited
a few times.

On admission: Temperature, 98° F.; pulse 130 ; nystagmus to the right.
Deviation to the right when pointing with right upper extremity. No asynergia
’■no dysdiadokokinesia, and finger-to-nose test was correct). Reflexes normal,
except doubtful plantar response.

Schwartze operation : Very small extradural abscess, mesial side of sigmoid
sinus. Exploration of cerebellum through this area, and about i oz. of pus
evacuated. Tube drainage.

The boy i9 still in St. Bartholomew's Hospital, and appears to be progressing
favourably at the time of writing.

I ventured to bring forward these few cases of brain abscess as examples,
on the one hand, of the comparatively scant clinical evidence which would
have justified a clinical diagnosis of abscess in each case, and on the other
band, the fortuitous circumstances on which recovery depends. These cases
do not comprise all we have met with during the last eighteen months, for
some others which appeared as likely to recover have succumbed. Of the
fatal cases, two cerebellar abscesses developed meningitis later, and in one case
°f temporo-sphenoidal abscess which had been diagnosed and drained within
three weeks of the onset of acute otitis media, and had almost recovered,

Scott: Cerebellar Abscess

there developed a very slowly spreading oedema of the brain, which terminated
fatally about two months later. The autopsy in the last case proved that
the abscess was efficiently drained, and there was no meningitis or intra¬
ventricular effusion, only oedema of the left cerebral hemisphere—a diffuse
form of infective encephalitis.

DISCUSSION.

Mr. Lawson Whale asked whether Mr. Scott considered that amnesia was still
present. This girl, when a watch was shown to her, called it a clock; whereas any
girl aged 11 might be expected to know the difference between a watch and a clock.

Mr. G. J. Jenkins asked whether Mr. Scott found “ Cushing’s defect ” in the
perimeter tracing in the first of these cases. He thought that for amnesia to be
present the abscess w T ould be further forward than in cases in which this defect was
likely to be obtained.

Sir CHARLES Ballance (President) said he thought that the presence of amnesia
was a sufficient ground for diagnosis, and in this case Mr. Scott had diagnosed the
condition at once, and had been able to save the patient’s life. A little before the war
he (the speaker) had as patient an officer who had undergone a mastoid operation for
long-continued otorrhcea. The nurse who was looking after him one day reported that
he had forgotten her name ; and when shown a watch he had been unable to name it.
He (Sir Charles) had gently removed the tegmen and incised the dura above it. The
dura was not pulsating, and was discoloured. There was no abscess, but the part of
the brain above the tegmen was in a condition of cellulitis. Drainage through the
dura was continued for ten days, and the patient had recovered. Shortly before his
complete recovery he had been able to distinguish and name objects, and afterwards
he had remained well.

Mr. A. J. Hutchison remarked that the patient in the second case could use his
hand well, except for buttoning and unbuttoning, and the disability in this respect was
due to his having lost sensation in the tips of fingers and thumb.

Mr. E. Musgrave Woodman asked what would be the best method of draining
cerebellar abscess in contradistinction to abscess of the temporo-sphenoidal lobe. If
cerebellar abscess were approached from the aural region, pus welled up from the
bottom, and everything looked satisfactory, but it was upward drainage, and in most of
the cases which he had seen the patients died. In approaching the abscess from below,
if there was a dural space which was not shut off by adhesions, there was a risk of
infection and the production of meningitis.

Mr. W. M. Mollison suggested that the numbness of the finger tips might be due
to congestion of the cerebral cortex, in consequence of the temporary cessation of
respiration.

Mr. G. J. JENKINS, referring to the danger of meningitis in cases of abscess,
said that recently, in two cases, he had put B.I.P. round the edges, getting between
dura and brain. It was a special preparation of B.I.P., without paraffin, and the
components sterilized separately. He thought it acted as a wall to prevent the
extension of sepsis. He believed that the statistics of the results of treatment of
brain abscess would give a gloomier picture than was generally thought.

Mr. Musgrave Woodman said he understood that at Queen Square Hospital
intratracheal ether w*as being used as the anaesthetic in brain cases. At Birmingham
they were using oxygen and chloroform intratracheally. With this method of anaesthesia
it was not material if the patient breathed voluntarily or not.

Mr. H. J. Marriage said that he had once had to operate at a cottage hospital on
a child under artificial respiration in a case of acute mastoid disease. It had been
obvious that a brain abscess was also present, but there had been no localizing

Section of Otology

symptoms to show where it was situated. Just after the administration of the
anesthetic had begun, the child ceased to breathe, and this circumstance pointed to
the cerebellum as the site of the abscess. The Silvester method of inducing
artificial respiration had been carried out for ten minutes, without any return of
breathing, although the pulse had remained quite good. The assistant had then
employed a modified Silvester’s method, bringing the arms up to the level of the
shoulder and then pressing them forcibly against the chest. While this was being
done he (Mr. Marriage) had trephined over the cerebellum. As soon as the trochar
had been inserted, pus had escaped, and the breathing had immediately recommenced.
For the moment he (the speaker) had been satisfied with putting in a drainage tube
and leaving it. Next day he had opened up the mastoid and found a track running
l>eneath the lateral sinus into the abscess. He had put drainage tubes into both
wounds, and for a week the child had done very well. Then it had suddenly rolled
over and died. Post mortem, not only a cerebellar abscess had been found but also
a temporo-sphenoidal abscess, of which there had not been any symptoms.

Mr. Cleminson said that he had had an opposite experience in connexion with cere¬
bellar absceBs (in a girl aged 15). While the pus was draining out, the patient had
stopped breathing, and though artificial respiration had been carried on for six hours,
she had never breathed again. At that time there had been no intratracheal apparatus
in the hospital for the administration of the anaesthetic, but he felt that if a tube could
have been introduced through the larynx and air insufflated, possibly the oedema which
caused pressure on the edge of the foramen magnum might have subsided. If he had
to operate again in a case of cerebellar abscess he would have an intratracheal anes¬
thetic, because the tube could be left in position, and air could be blown into the lungs
indefinitely.

Sir Charles Ballance (President) said that in his experience as soon as the dura
was opened respiration was resumed. In one case he had had at Queen Square artificial
respiration had been carried on for five hours ; he (Sir Charles) had performed crani¬
ectomy, and as soon as the dura had been opened, the patient had begun to breathe
again. This had also been the case during his operations on cerebellar tumours and
abscesses, breathing had begun again as soon as pressure had been removed from the
medulla. In the cases with which he had had to deal the Silvester method of artificial
respiration had been employed. The most important point was that of the prevention
of meningitis in cases of brain abscess in w p hich there was no matting of meninges.
That was a problem which, he thought, had not yet been solved. Some members had
suggested putting various materials underneath the dura before opening the abscess;
but it was not easy—owing to the pressure—to introduce anything between the dura
and the arachnoid, before opening the abscess, and even if that was done, the sub¬
arachnoid space was not shut off. He (the speaker) had tried putting pieces of gauze
which had been soaked in some solution between the dura and the arachnoid, simply
closing the subdural space in that way, or putting in B.I.P. But that was not all that
was necessary; the subarachnoid space must also be closed, for it was in that space
that one desired to avoid the possibility of meningitis. In some cases, when he had
opened the brain abscess, he had been unable to prevent the extension of infection to
the subarachnoid space, through healthy brain tissue without matting of the meninges.
If this problem could be solved the lives of the patients in these cases could be saved.
Then w p e should not have to search for the pathological track through which the
infection had entered the cranial cavity.

Mr. SYDNEY SCOTT (in reply) said that artificial respiration had been performed
hy the anesthetist, Dr. R. Wade and the house surgeon, Mr. Prance, the sister of
the ward acting as chief assistant while he exposed and opened the cerebellum.

Mollison: Case of Vertigo: Cured

Case of Vertigo cured by Opening the External
Semicircular Canal.

By W. M. Mollison, M.Ch.

H. E., AGED 42, was seen at Guy’s Hospital in September, 3922; for two
months he had suffered from giddiness and tinnitus in the left ear. The
giddiness came on suddenly while he was driving a van, objects rushed to the
left and he “felt queer”; the attack gradually passed off. The attacks recurred,
sometimes he had as many as three a day; on one occasion he fell in the fire
and burnt himself severely. Examination of the ears showed normal
membranes. Hearing in the right ear was good, in the left ear almost absent.

No spontaneous nystagmus was seen. Caloric response on both sides was
sluggish ; indeed it was doubtful whether any response was obtained on the
left side. Past pointing normal on the good side (right) and absent on the
deaf side. Dr. Symonds examined the patient and found no sign of intra¬
cranial lesion. It was decided to open the left external semicircular canal.
This was done in January, 1923. Within four weeks of the operation the
patient was entirely free from vertigo and could hear a whisper at a distance of
8 ft. from the left ear.

I have not seen the man for six weeks, but I have tested his hearing to¬
day, and find that he is deaf in the affected ear.

DISCUSSION.

Dr. Dan McIvENZIE asked whether Mr. Mollison could say what the lesion might
have been. He (Dr. Mackenzie) remembered the suggestion that in some cases of
vertigo there was a state similar to that in the eyeball in cases of glaucoma; that is to
say the condition was due to pressure. He thought this theory would explain the
symptoms in the present case ; first the attacks of deafness, secondly the relief following
the opening of the external canal.

Dr. Kelson said that he had had a similar case in 1913. The patient, a house
painter, had been so giddy that he could not go up a ladder in the course of his work.
He (Dr. Kelson) had operated on the right external semicircular canal, in a similar way
to that described, and had shown the patient at a meeting of the Section in 1914. At
that date he had practically lost the giddiness and the tinnitus. Since half the benefit
from recording such cases was lost if they were not followed up, he (Dr. Kelson) had
written to the patient’s doctor, who had reported, in 1916, that the man was well,
could again climb ladders and do his work and no longer had tinnitus. In 1921, eight
years alter operation, the report was that the man had kept well until the previous
September, when he had again begun to have attacks of giddiness, and some degree
of tinnitus.

Mr. Archer Byland said Mr. Mollison had certainly achieved a good result in
this case, for not only had there been a total abolition of the vertigo, but the hearing
had very substantially improved. He (Mr. Byland) did not know if Mr. Mollison
would strongly advocate this operation for the relief of vertigo. He (the speaker)
w r ould feel very hesitant about opening the external semicircular canal for that
purpose. He had on one occasion opened this canal inadvertently in the course of an
ordinary radical mastoid operation, and a prolonged and troublesome vertigo had
resulted.

Sir James Dundas-Grant said he supposed the idea was that in this case there
had been an increased tension in the fluids of the internal ear. He asked what had

Section of Otology

been the steps in the operation. The middle ear had been preserved intact. He
(Sir James) suggested that if the operation on the external semi-circular canal was to
entail loss of hearing, it would be safer, and to many of us easier, to remove the
tympanic membrane and ossicles completely, thereby allowing more room for the
expansion of the internal liquids, through the freer play of the annular ligament in the
fenestra ovalis. That greater play might suffice to relieve the pressure.

Mr. Lawson Whale said that he had done this operation deliberately in two
cases. He had to do the radical mastoid operation first, otherwise he would not have
obtained access to the mastoid horizontal canal. He made a } in. opening immediately
above and parallel to the horizontal part of the facial canal, and he would like to hear
how large an opening Mr. Mollison had made, and how much exposure of the semi¬
circular canal he had secured. He would also like to know how long after the operation
compensation for the loss of labyrinthine function had occurred. In his own cases
the patients had been giddy for three weeks, and had then recovered.

Mr. MOLLISON (in reply) said that beyond accepting the suggestion that these
cases might be compared to those of glaucoma, he had no theories. He approached
such cases, from an operative point of view, with considerable hesitation. In the
cases (four in number) in which he had operated, the hearing in the affected ear had
been much diminished; in two it had been practically absent. Three of the patients
had been taken into hospital and carefully examined by physicians before it had been
decided to operate. In two of the cases he had operated at the request of the
physician, as the patients’ lives were a burden as a result of vertigo. In one case, that
of a clergyman, there had been attacks for two years; the second case was the one
shown to-day. In the third case the patient was a publican whose vertigo had been
so severe that he had had to give up all his work. The fourth case was that of a
private patient, who had consulted Dr. Hurst. He (Mr. Mollison) had found the
operation so easy that he feared he might be tempted to perform it without due con¬
sideration. He opened the mastoid exactly as for ordinary mastoidotomy, exposing
the aditus region as fully as fora mastoid, so as to get a good view of the external semi¬
circular canal; he then chipped open the canal. He had not formed a conclusion as to
the best course to pursue after that. In the first case, remembering Mr. Sydney
Scott’s experiments on pigeons, he had injected absolute alcohol into the canal, in
order to destroy the function of the labyrinth. The result had been fortunate; it was
more than two years ago since the operation, and the patient had resumed work and
had had no more vertigo. In the second case alcohol had not been injected, and all
vertigo had ceased. In the third case pure carbolic acid had been applied, and the
attacks had ceased absolutely. The fourth case was so recent that the result was not
yet known. The operative treatment of cases of non-suppurative labyrinthine vertigo
had been suggested many years ago by Mr. Cheatle, and carried out by Mr. Lake,
Mr. Jenkins, Mr. Hugh E. Jones, Mr. Sydney Scott, and others.

The difficulty consisted in selecting cases in which operation was indicated, and in
excluding extra-labyrinthine causes for the vertigo.

Sequestra removed from the Region of the Eustachian
Tube during a Radical Mastoid Operation.

By T. H. Just, F.R.C.S.

The patient, a female, aged 23, had suffered from suppuration in the right
ear since childhood. For six weeks before being seen by exhibitor she had had
a right-side facial palsy. She died suddenly, five days after a radical mastoid
operation. An autopsy showed extensive osteitis, practically the whole of the
petrous portion of the temporal bone being involved.

62 Just: Ependymal Glioma , simulating Cerebellar Abscess

Section of Ependymal Glioma growing from the Floor of
the Fourth Ventricle, simulating a Cerebellar Abscess,
in a Case of Bilateral Chronic Suppurative Otitis
Media.

By T. H. Just, F.R.C.S.

The patient, a male, aged 26, complained of double otorrhcea of long
standing, and of symptoms indicating that the left cerebellar fossa was involved.
On exploration, the cerebellum bulged under pressure but no abscess was
found. The patient became worse, and a more thorough exploration was made
but the result was negative. The patient suddenly died of respiratory failure
two days later. Post mortem, an ependymal glioma was discovered, arising
from the floor of the fourth ventricle. The tumour would have been absolutely
irremovable.

PROCEEDINGS

OF THE

ROYAL SOCIETY OF MEDICINE

EDITED BY

Sin JOHN Y. W. MacALISTER

UNDER THE DIRECTION OF

THE EDITORIAL COMMITTEE

VOLUME THE SIXTEENTH

SESSION 1922-23

SECTION OF PATHOLOGY

LONDON

LONGMANS, GREEN k CO., PATERNOSTER ROW

192 3

Section of pathology

OFFICERS FOR THE SESSION 192*2-23.

President—■

.T. C. G. Ledingham, C.M.G., M.B., F.R.S.

Vice- Presidents —

J. A. Murray, M.D.

J. McIntosh, M.D.

Hon. Secretary—

E. H. Kettle, M.D.

Other Members of Council—

A. J. Eagleton, M.D.

Alexander Fleming, F.R.C.S.

W. E. Gye, M.D.

Frederick T. G. Hobday, C.M.G.
C. E. Lakin, M.D.

W. S. Lazarus-Barlow, M.D.

C. J. Martin, C.M.G., M.B., F.R.S.
J. C. Mottram, M.B.

R. A. O’Brien, M.D.

Cecil Price-Jones, M.B.

Sir Bernard Spilsbury, M.B.

F. H. Teale, M.D.

Representative on Library Committee. -
W. Bulloch, M.D., F.R.S.

Representative on Editorial Committee —

S. G. Shattock, F.R.C.S., F.R.S.

SECTION OF PATHOLOGFi

CONTENTS.

October 17, 1922.

Professor J. C. G. Ledingham, C.M.G., M.B., F.R.S. page

President’s Address: Natural Resistance and the Study of Normal

Defence Mechanisms ... ... ... ... ... ... 1

November 21, 1922.

J. C. Mottram.

Some Effects of Exposure to Radium on the Blood Platelet< ... ... 9

Cuthrert Dukes, O.B.E., M.D., D.P.H.

A New Fermentation Tube, in which Carbohydrates may be separated

from Proteins during Sterilization ... ... ... ... 18

February 20, 1923.

S. G. Shattock, F.R.C.S., F.R.S.

The Disruptive Phenomena in Gunshot Injuries : their Physics ... 17

S. C. Dyke, M.B., B.Ch., D.P.H.Oxon., and C. H. Budge, M.R.C.S., L.R.C.P.

On the Inheritance of the Specific Isoagglutinable Substances of Human
Red Cells. With a Note on the Possible Existence of a Lethal
Factor by S. C. Dyke ... ... ... ... ... 35

The Society does not hold itself in any way responsible for the statements made or
the views put forward in the various papers.

London :

John Bale, Sons and Danielsson, Ltd.,

Oxford House,

83-91, Great Titchfield Street, Oxford Street, W. 1.

Section of pathology

President—Professor J. C. G. Ledingham, C.M.G., M.B., F.R.S.

Natural Resistance and the Study of Normal Defence

Mechanisms:

PRESIDENT’S ADDRESS.

By Professor -J. C. G. Ledingham, C.M.G., M.B., F.R.S.

SOME form of address from newly-elected presidents has been customary
in the past, and I would desire your forbearance while I review certain aspects
of immunity which have long baffled the experimental pathologist and which
are certain to receive in the future more adequate consideration when the
fundamentals of the science of immunity like those of all experimental sciences
come to be relaid.

The phenomena to which I direct your attention come in the category of
what is known as natural immunity or natural resistance—a subject vast and
many sided—and I propose to consider simply what amount of light has been
thrown on the elucidation of certain well-known instances of natural immunity
to bacterial infection, by the study of the bactericidal functions of body cells
and fluids. The infection I choose for illustrative purposes is that of anthrax,
largely because it has been in connexion with the peculiar and fascinating
divergencies of susceptibility exhibited by animal species towards this infection,
that defence mechanisms have been tested with a view to their elucidation.

Some preliminary considerations need ventilation before I proceed to the
main theme. When we consider the enormous output of literature on
immunity which, since the beginning of the century has followed regularly
the discovery of some new defence mechanism, we have reason to feel that
some sufficient explanation might have heen vouchsafed for the existence of
these peculiar resistances, but as I hope to show you to-night, there is no
subject in immunity which has been so persistently and yet so inadequately
explored. The discovery of a new immunity mechanism has led in the first
instance, as a rule, to its intensive exploitation for diagnostic or therapeutic
purposes, and rightly so in the main. Some mechanisms have lent themselves
more readily than others to such exploitation. Many again have failed to
attract anything but a passing fancy and they have been promptly forgotten
or ignored, while the great flood of freshly gathered facts and fictions has
continued to roll on uninterrupted. And yet if, as I believe, knowledge is best
grasped in its historical setting, then surely these half-forgotten theses must
claim the attention of the serious investigator. I am no lover of the archives
for their purely bibliographic interest, but I firmly believe that were more
attention paid to the archives by the average investigator, not only would

I>—Pa 1 [October 17, 1922.

Ledingham : Natural Resistance

there be a welcome reduction of much unnecessary literature, but a keener
vision of our science as a whole and a greater ambition to build truly. Even
in my very brief working experience I have seen many an instance of failure,
innocent usually, sometimes possibly deliberate, to fit some apparently novel
fact into its proper setting in the great edifice of natural knowledge. None the
less, with the colossal mass of literature on pathology, bacteriology, and
immunity on our shelves, it is no easy task to comply with the historical
method. To take the subject of immunity alone, it may be remembered that
no fewer than twenty volumes of the Zeitschrift fur Immunitatsforschung
appeared in the five years preceding the war—a truly vast encyclopaedia of
alleged fact—and this single effort represented only a fraction perhaps of the
total output for the period in question. In face of this, how is the junior
investigator to be directed to lay his bricks in an edifice the alignment of which
he cannot possibly know ? The task, I admit, is hard, but I maintain that the
ambition should ever be to build truly on the historical past so that when
the time comes for synthesis the old bricks may simply require relaying.
The real expert must aim to be a man of vision with a working knowledge of,
and a pride in, a glorious historical accomplishment. A mastery of technique
is often, in my opinion, of much less relative value.

The Problem of Natural Immunity.

Natural immunity remains a dark corner in our edifice. Immunology as an
essentially experimental science has undoubtedly gained its chief triumphs
in the domain of acquired immunity. It has sought with marked success not
only to imitate the immunity that is seen to follow successful combat with the
actual disease naturally contracted, but also to transfer the chief bearer of that
immunity from the immune subject, be it recovered human or immunized
horse, to the acute case. In some notable instances we seem to know with
certainty what we are doing in so acting, that, for instance, the passive fluid
injected represents simply so many units of an accurately titrated substance,
suspended, we shall say, in a vehicle of serum. So far as we are able to judge
experimentally, the vehicle itself might be indifferent. In any case, if it has
effects of its own apart from its known content of titratable substance, and
there would appear to be some clinical evidence of their presence, these effects
are not such as can be readily repeated or experimentally controlled. In other
cases in which the passive transference of immune serum is followed by
undoubted success as, for example, in anthrax, it has so far been impossible
to determine precisely what particular principle in the serum so injected is
responsible for the success. In other infections again, such as the coccal
septicaemias, the success achieved has been but partial and fortuitous. Either
the systems of titration on an in vitro basis have been unsatisfactory or,
when biological titration has been partially possible, the existing great variety
of cocoal types both in man and animals and their contrary affinities for
various animal species will doubtless long militate against the elaboration
of any rational and stereotyped scheme of serotherapy in these infections.
We may learn, however, from our difficulties. We can see that nature,
specifically unaided, can successfully circumscribe the sphere of operation of a
coccal or even an anthrax infection while she may fail to control a general
invasion. We note also that nature not infrequently appears to derive much
assistance in the control of infection from the inoculation, for example, of a
normal serum or from the inoculation of some type of colloid fluid circum¬
spectly administered. Possibly the not infrequently observed phenomenon of

Section of Pathology

the incompatibility of double infections may be placed in the same category
of facts. In any case there would appear to be abundant justification at the
present stage of immunological research for the closest study of the normal
defence mechanisms.

The Mechanisms of Defence.

It is a strange circumstance that those curious instances of normal
resistance which are referred to in all the text-books, should rest on such an
insecure basis of fact from what might be called the quantitative standpoint.
They, and the alleged explanatory mechanisms, appeared to fascinate the
earlier workers intensely, but the experimental work they devoted to their
solution cannot now be regarded as authoritative in the light of present
knowledge. It seems that as each new mechanism of defence was discovered
it was immediately tested and generally found to explain the observed
resistance to the satisfaction of the discoverer. In what follows I shall
illustrate what has happened in the case of anthrax and draw certain inferences
as to future lines of progress. Put succinctly, the problem before us is simply
this: Is the mechanism of a certain case of natural resistance capable of full
and satisfactory expression in terms of test-tube analysis ? Or must
mechanisms other than those with which we are familiar be called in to
explain the phenomenon ?

Earlier Contributions to the Subject.

The mechanisms are not many and it would appear advisable to summarize
them briefly before discussing their application to the problem in question.
What contributions to the mechanism of defence were made by the great
masters of general pathology and cytology of the past half-century ? I need
not discuss, even if I possessed the necessary knowledge, the various doctrines
and conceptions of inflammation that formed the basis of pathological teaching
of possibly most of us, but it is very obvious from even cursory analysis of the
works of the great masters that the phenomena of inflammation gradually but
surely came to be regarded in the light of natural defence mechanisms. That
this was so is abundantly evident at the commencement of the present century
and in illustration I may cite the inaugural address of Marchand, a valued
teacher of my own, on assuming the chair of Cohnheim at Leipzig in 1900. The
title of his address was “ Ueber die naturlichen Schiitzmittel des Organismus,”
and it was an attempt to summarize, in the sense of defence mechanisms, the
various changes produced in the course of the inflammatory process-changes in
the circulation of the part, in the circulating blood elements and in the fixed
tissue cells, the local leucocytic response, the clearing or scavenging of the
infected area presumably brought about by ferments from living or broken-down
leucocytes, the restoration of the circulatory mechanism by newly-formed
vessels growing on a scaffolding of fibrin and perhaps gaining the necessary
energy for their development from the discharged effusion, the consolidation of
the whole by newly-formed tissue derived from the fixed tissue cells of the
part—these and many other processes he regarded as essentially defence
mechanisms depending on the reactivity of the local tissues.

On the whole I receive the impression from reading the works of these
masters that their methods of work were too local and circumscribed to render
the results capable of general applicability to the phenomena of bacterial
invasion. They had little conception then of the vast potentialities for defence
residing not only in the fluids circulating in the inflamed part but also in the

Ledingham: Natural Resistance

emigrated leucocytes and possibly also in the fixed tissue cells. Since those
days the immunologist has had his innings, but I am of opinion that we shall
return to the consideration on ampler lines of local condition and function in
the widest sense if we are to understand thoroughly the rationale of natural
immunity. Already one sees a tendency towards the combined histological
and serological attack on these problems.

Metchnikoff's Conception of Phagocytic Action.

I pass to Metchnikoff, whose attempt to extend the sphere of phagocytic
action from the physiological to the pathological field and to read into it the
idea of a protective mechanism with an application to all higher animals
possessing circulating amoeboid elements, constituted the first large-scale
conception calculated to raise the lore of inflammation from one of purely
local to one of the most general application. It was, in fact, the commence¬
ment of immunity as a general science. To Metchnikoff the leucocyte came to
be endowed with particular qualities and properties according to the reactivity
of the host. It was, moreover, the source par excellence of any and all
bactericidal substances that might be present in cell-free fluids of the body.
The constant polemics into which his rigid adherence to the conception of the
all-sufficiency of the phagocyte led him are now matters of history, but it
has to be remembered that these very polemics with the rising school of
humoralists led by Nuttall, Buchner, and a host of others, gave the stimulus
to uncounted researches on the properties and sources of growth-inhibitory
and bactericidal bodies in tissues and fluids. Metchnikoff sought to retrieve
the position of the phagocyte by many ingeniously contrived experiments, but
it was obvious that opinion was definitely ranged alongside the newer humoral
ideas while the ultimate source of the alexin and the intermediary body or
substance sensibilisatrice , the co-operative action of which with a thermolabile
alexin was later demonstrated, were left more or less open questions. The
final demonstration by Denys and Leclef, Mennes, and others showing the
dependence of phagocytic action in immune serum on the presence of a
substance sensibilisatrice and the extension of the principle to normal serum,
by Wright and Douglas, constituted a reasonable enough reconciliation between
the opposing views. We know, however, that absolutely independent phago¬
cytic action cannot be excluded as a defence factor, especially when organisms
of low virulence are in question, and researches on spontaneous phagocytosis
have demonstrated that in a given collection of leucocytes exposed to organisms,
some/ individuals undoubtedly appear to possess much higher phagocytic
powers than others. We have not reached the end of this particular problem

Properties of the Normal Alexin.

After the phagocyte came the alexin of the cell-free fluids. The complex
nature of the normal alexin and its presence both in plasma and in cell-free
serum are now fairly generally accepted facts. It should be noted, however,
that the complex nature of the normal alexin is much more difficult to
demonstrate than that of the so-called bacteriolysin in immune serum, and,
as we shall see, there is now evidence that certain normal sera possess
considerable bactericidal and growth-inhibitory effects which are not destroyed
by the usual inactivation temperatures. In fact, the test-organism in all these
matters is of prime importance. Here it is sufficient to note that the normal
alexin can kill or dissolve certain organisms while others are unaffected or at
most suffer growth inhibition.

Section of Pathology

Properties of Leukins.

I pass to the leukins or the bactericidal substances present in extracts of
leucocytes. The study of these arose largely out of the views expressed by
Buchner and Metchnikoff that the source of the alexin might possibly be found
in such substances. The chief work on this defence mechanism, which has
not perhaps attracted the attention it deserves, has been that of Hahn,
Schattenfroh, Petterson, Kling, Manwaring, Schneider, and Petrie in this
country. I need not recapitulate the various methods employed for securing
potent extracts. These will be found in all text-books, but it is quite clear
that the methods of extraction influence greatly the potency of the resulting
product. These extracts do not lose their power of killing certain test
organisms after heating, say, at 60° F. They can resist very much higher
temperatures, even up to 80° F. The constitution of these leukins or endo-
lysins is still uncertain. Some workers have attempted to show that they
possess complementing powers in the presence of inactivated sera, but others
have entirely failed to confirm such action. Petterson would say that these
extracts contain both an alcohol-soluble and an alcohol-insoluble fraction, and
that the one can inhibit the action of the other: These effects, however, are
almost certainly to be reckoned in the category of inhibition phenomena ex¬
plicable on colloidal principles. The chief interest of the leukins lies in the
effects they produce on different groups of organisms, and in the similarity of
such effects to those produced by very analogous extracts prepared from tissues,
and which were demonstrated twenty years ago by Conradi, Korschun and
Morgenroth, Tarassewitsch, and others. These leukins have, as a rule, been
tested against organisms of the typhoid-coli group and organisms of the subtilis
group, to which anthrax belongs. Curious differences have been shown by
extracts of leucocytes of various animal species in their action on bacterial
types. Thus guinea-pig leucocytic extracts are said to possess little or no
bactericidal action on Bacillus typhosus , while those from the rabbit are
distinctly potent. Petrie, how r ever, using extracts prepared from leucocytes
triturated at a temperature of liquid air failed to demonstrate bactericidal bodies
for Bacillus typhosus in rabbit leucocytes. The leucocytic extracts of the hen
have, according to Schneider, no action on Bacillus typhosus , but a very con¬
siderable action on Bacillus anthracis . On the other hand, the serum of the
hen can kill Bacillus typhosus , but has little action on Bacillus anthracis , so
that it would seem that absence of bactericidal property in the extract of a cell
might be compensated by its presence in the surrounding fluid, and vice versa.
The study of bactericidal bodies in tissue extracts and body secretions is again
being actively pursued in connexion with bacteriophage problems. In the so-
called bacteriophage, from whatever source it may be obtained, there is
exhibited the same thermostability and the same limitation of action to certain
bacterial groups . Rapidity of action of these leucocytic extracts on organisms of
the subtilis group and slowness of action on organisms like Bacillus typhosus ,
with subsequent overgrowth of presumably resistant organisms, are features
which recall those noted in investigations connected with the bacteriophage and
with the bactericidal bodies present in egg-white, as demonstrated by Rettger
and Fleming.

I close this subject by noting the existence of the thermostable bactericidal
body in rat serum. This body has been carefully tested by Pirenne against
organisms of the subtilis group, and also organisms like Bacillus coli and
Bacillus pyocyaneus. Plating experiments have shown that organisms like

Ledingham : Natural Resistance

Bacillus mycoides , Bacillus megatherium , Bacillus subtilis , are rapidly killed
off, while Bacillus proteus , Bacillus coli , and Bacillus pyocyaneus multiply
freely. The cholera vibrio is also killed off, but this action was found to be
due to the ordinary thermolabile alexin in the rat serum, and it disappeared
after inactivation of the serum.

Proteolytic Bodies in Leucocytes .

There remain only the proteolytic bodies contained in leucocytes; these
have been studied by many workers chiefly in connexion with the so-called
anti tryptic action of serum. We know little or nothing of their action on
bacteria, and indeed it would be difficult to separate any such action exhibited
from that due to the more generally studied endolysins. I may just mention
the alleged existence of bactericidal bodies in platelets, a subject introduced by
Gruber and Futaki in 1907, and but little studied since. These authors
came to the conclusion that the bactericidal action on anthrax of normal
rabbit serum (a highly susceptible animal) depended on substances derived
from the platelets. Barreau, who continued this work, found that the serum
of the dog (a highly resistant animal to anthrax) had no action on anthrax nor
had its platelets. He concluded, however, that the platelet bactericidal bodies
or plakins probably did not play much of a part in natural resistance, as the
rat, for instance, a resistant animal, was rich in plakins, while the rabbit, a
susceptible animal, was equally so. It is possible that the recent work on
the purely mechanical function of blood platelets in removing suspended
organisms by virtue of their adhesive properties may throw a different light
on these alleged bactericidal substances in platelets.

Animal Experiments.

The application of these defence mechanisms to the elucidation of natural
resistance to anthrax can now be very shortly considered. The resistant
animals chiefly studied have been the frog, the fowl (especially the hen and.
pigeon), the rat, and the dog, but, as I have indicated before, we have no
accurate data of a quantitative kind as to the extent of this resistance in
most cases. There is no doubt that the frog presents an extraordinary re¬
sistance to anthrax infection—a resistance which in the early days was attri¬
buted to its low body temperature. Attempts were made to infect frogs kept
at 37° C., and in these circumstances the animals readily succumbed.
Metchnikoff attributed the deaths in these cases to diminished phagocytic
action, whereas in the frog, the temperature of which was not interfered with,
exuberant phagocytosis at the seat of inoculation afforded sufficient explana¬
tion of the immunity. The humoralists, however, maintained that the
immunity was due to the bactericidal properties of the local lymph (Nuttall,
Baumgarten, Petruschky, &c.). Metchnikoff countered this by showing that
Bacillus anthracis could grow readily in frog plasma. Galli-Valerio favoured
the combined action of phagocytosis and bactericidal property of lymph as the
most likely explanation. The matter remains quite obscure, and a more recent
worker, Ditthorn, simply states that anthrax rods inoculated in any way into
frogs show degenerative changes in a few days and lose their contours. The
test organisms may, of course, play a decisive r6le in view of the fact that
Dieudonn6, for example, cultivated a race of anthrax growing abundantly at
12° C., and with it succeeded in killing frogs readily. These experiments
require confirmation.

Section of Pathology

With regard to fowls, the hen and pigeon, and particularly the hen, are
known to possess high resistance, and in the classical experiments of Pasteur
and Joubert, in 1878, the immunity was attributed to the high body tempera¬
ture of the fowl. By immersing the fowl in cold water infection took place.
The death under such circumstances has been attributed by later workers to
a general lowering of resistance, and not to an inability on the part of
Bacillus anthracis to grow at the high temperature of the fowl. Metchnikoff
maintained that phagocytosis in the normal hen was rapid and complete, and
in the cooled hen very poor. Later, Thiltges stated that phagocytosis was
not in evidence, and that the immunity was due to the bactericidal action of
the plasma, a property which Gengou denied. Thiltges agreed, however, with
Metchnikoff in the matter of the pigeon. Bail and Petterson and Schneider
ascribe the resistance to the action of the hen leukins, which act very power¬
fully on Bacillus anthracis , while the serum has relatively little action. Donati
in a more recent communication ascribes the immunity of the fowl simply to
a local invasion of leucocytes, which hinder capsule formation, and by virtue
of bactericidal substances secreted by them, and not by phagocytosis, secure
the removal of the invaders.

It is notorious that the adult dog can tolerate without inconvenience the
inoculation of large quantities of bacilli, and, as one might expect, this im¬
munity has been attributed by Metchnikoff to phagocytosis at the site of
inoculation. Hektoen later showed that in the presence of dog serum dog
leucocytes readily took up Bacillus anthracis. It would appear that the serum
of the dog has but little or no anthracidal action as compared, for instance,
with that of the rabbit, which is, on the contrary, a fairly highly susceptible
animal. While without action on Bacillus anthracis , dog serum, according to
Petrie, has a powerful action on Bacillus typhosus. Hektoen attributes
some importance also to the leukins of the dog. Petrie, however, found none.

The rat presents a more interesting problem, though it has to be remembered
that there is no absolute immunity in this species. Behring, in 1888, showed
that rat serum was anthracidal, while Metchnikoff found that the main defence
was the phagocytic response- The thermostability of the bactericidal body in
rat serum, as shown by Pirenne and Horton, is a most interesting feature. It
acts equally well at 18° C. as at 0° C., and remains active for fairly long
periods in the cold.

Summary.

To summarize, it must be confessed that the curiously contradictory and
yet perhaps genuinely reasonable explanatory theses give us little that is solid
to hang on to. No one instance of normal immunity has yet been investi¬
gated as a complete problem. Partial mechanisms only have been studied.
The hearer might well conclude that dogs are immune because dogs are dogs,
and so for rats, fowls and frogs, but that would not be quite the impression I
should like to make. If a certain animal is immune to a particular experi¬
mental infection, such as anthrax, one ought to be able to explain fully what
local phenomena have occurred to prevent a general invasion by the organism.
To do so effectively must involve the testing of each possible mechanism
separately and in conjunction, and it must involve a return to the cytological
study of the changes which the invading organism undergoes in situ. The
problem must be attacked not only by methods which derive their authority
from long experience with the bactericidal properties of cells and fluids, but
also by methods which reflect the trend of present-day studies on general

Ledingham: Natural Resistance

metabolism both of parasite and host. With regard to the former much has
been made of the capsule, but the data on the point are contradictory. In
every set of experiments strict attention must be paid to the maintenance of
virulence. It may, indeed, be found that by experimental selection a test
organism which has once proved virulent for one individual of a resistant
species may prove equally so for all individuals of the species. Strains of
Bacillus anthracis have been thus selected which are alleged to have killed
fowls, rats, and frogs, but the experiments lack confirmation.

Another important aspect of the subject which has recently been brought
to the forefront by Besredka relates to the site of inoculation of the test
organism. In the course of his researches on the production of immunity by
vaccinating that portion only of the body which is most susceptible Besredka
has turned his attention to anthrax infection in the guinea-pig, an animal
notoriously difficult to protect by any method of vaccination. He shows ex¬
perimentally what, by the way, had been amply demonstrated twenty years ago
by Noetzel, that animals like the rabbit and guinea-pig can tolerate easily
doses of virulent anthrax if introduced directly into the circulation or into the
peritoneal cavity without the cutaneous tissues being contaminated. This
contamination can be avoided by a special and careful technique. According
to Besredka the skin of the guinea-pig is the only susceptible portion of the
guinea-pig’s anatomy, and if it had no skin it would be a highly refractory
animal instead of being, as it is, one of the most susceptible. He further
demonstrated the possibility of securing solid immunity to anthrax, by what¬
ever route inoculated, by vaccination of the skin with the attenuated Pasteurian
vaccines. I do not wholly accept much of the evidence adduced so far in
support of the conception of partial or local immunities or susceptibilities,
but I believe the matter is worth the fullest investigation. In any case it is
obvious that future work on natural resistance must take count of the pos¬
sibility of very diverse immunities or susceptibilities apparently combined in
one immune whole.

I have dealt in this address with species resistance solely, but it has to be
remembered that there are racial variations of resistance within the species.
For this reason the study of the mechanism of normal immunity will doubtless
demand the services, of the geneticist, who will be responsible for securing
pedigreed stock for experimental purposes. This is no fanciful suggestion.
In connexion with these most promising developments in experimental
epidemiology which are being carried out in this country and in America
the services of the geneticist must be invaluable. The dietetic factor, too, may
prove of supreme importance in experiments on natural resistance, and there
is already a body of evidence pointing in this direction. It is possible also
that we may learn something from comparative observations on the rationale
of natural immunity in plants to fungal infections. In a recent address by
Blackman some of these mechanisms reveal extraordinarily interesting relation¬
ships between the attacking fungus and the cells of the immune host. In
conclusion, I feel that I have touched but the fringe of this vast subject, but
if my exposure of the little we really know may stimulate further research
I shall be content.

Section of patbolofjs.

President—Professor J. C. G. Ledingham, C.M.G., M.B., F.R.S.

Some Effects of Exposure to Radium on the Blood Platelets.

By J. C. Mottram.

(From the Research Department of the Radium Institute.)

In a previous paper [1] it was shown that exposure to radium is followed
by a great diminution in the number of platelets in the blood. This has been
recently confirmed by Moller (2J. An exposure of rats to 0*46 rads gave
rise to a fall in platelets as shown on fig. 1, rats Nos. 1 to 5, where it is seen
that a return to the normal level occurs on about the twenty-second day.

Continuing these investigations, observations have been made in order to
discover what is the behaviour of the platelets after this return to the normal.
The results are shown in fig. 1, rats Nos. 6 to 9, and in Protocol I. They
show that after reaching the normal level a rise in platelet numbers occurs,
having its peak about the thirtieth day. This is followed by a fall, a second
return to the normal occurring in the neighbourhood of the fortieth day. The
red-cell counts present no equivalent changes, and the control observations

Ja—Pa 1 [November 21, 1922.

Mottram: Some Effects of Exposure to Radium

show that repeated blood examinations do not alter the platelet content in a
similar manner.

Experiments were next carried out in order to discover whether an increase
in platelet numbers could be brought about by repeated small exposures to
radium, similar to the lymphocytosis which follows small doses of radiation
frequently repeated [3]. Four rats were exposed daily to radiation for one
hour, and another set of four animals for an hour every other day. The
conditions of radiation were as tabulated in Protocol I. Eight unradiated
control animals were at the same time examined. After a few days the
radiated animals presented a fall similar to that shown in fig. 1, but less steep.
During the first few days, however, a number of counts much above the
normal were irregularly observed. The distribution of these counts is
compared with the controls in fig. 2, where it is seen that high counts occur
among the experimental animals; whereas in the controls no counts above
1*4 millions per millimetre were observed, in the experimental, five counts of
1*8 and one of 2*0 were found.

0-6 0-6 1-0 12 1-4 J-6 i-S 20

Fig. 2.

A more intense study of the early effects was therefore made with the use
of animals exposed for one hour twice a week. The results are given in fig. 3,
and Protocol II, and show a decided rise in the platelet counts, having a
maximum about the end of the second week. This was repeated on two more
animals (see Protocol III), one of which showed a very decided rise on the
tenth and twelfth days, and the other a less pronounced rise on the twelfth
day. In all these animals a rapid return to the normal occurred, although
exposure to radium was not discontinued. An exposure of one hour per week
was not followed by a change in platelet numbers, although the observations
extended over a period of eight weeks (see Protocol IV).

Observations were next made to see whether a similar transitory rise
preceded the profound fall produced by continuous radiation, as in fig. 1. The
findings are given in Protocol V, where it is seen that under an intensity of
radiation sufficient to produce a diminution in platelet numbers beginning at
about the fifth day, no preliminary rise occurred during the first four days.

The morphological characters of the platelets were not observed to vary
under these conditions of radiation. In some cases an increased density at

Section of Pathology

the centre of the platelet occurred, simulating a nucleus, but when fixed and
stained for chromatin it was seen not to be of the nature of a nucleus. The
stains which most strongly coloured the platelets were found to be those

especially powerful in stainihg protoplasm, such as eosin, acid fuchsin and
prolonged exposure to iron haematoxylin, and these also stained the central
opacity above mentioned.

12 Mottram: Some Effects of Exposure to Radium

The origin of platelets is still a matter of controversy [4] so that a
comparison of their behaviour under radiation with the behavour of the other
blood cells may perhaps give a clue as to their source. Under conditions of
continuous radiation, similar to those used in the above experiments, a
lymphopaenia occurs within a few hours, a polynuclear leucopsenia in about
seven days, and an anaemia in about fourteen days* so that the reaction of the
platelets is much more nearly comparable with the red-cell behaviour than
with the lymphocytic or polynuclear. This suggests that the platelets are
likely to be related in origin and morphology to red cells rather than to
leucocytes.

The possibility of being able either to increase or to diminish the platelets
offers a field of research into the function of these bodies, which is being
followed up, more especially with regard to their supposed action on micro¬
organisms [5]. Moller [2] is of opinion that the anaemia following radia¬
tion is the result of haemorrhages into the tissues conditioned by the
diminished platelet numbers.

Summary.

Prolonged exposure to radium causes a profound fall in the number of
blood platelets, which is followed by a return to the normal, then by a rise
above the normal, and finally by a second return to the normal level.

Repeated small doses of radiation give rise to a primary rise in platelet
numbers, which is, however, maintained only for a few days, when the normal
level is again reached.

REFERENCES.

[I] Cramer, Drew, and Mottram, Proc. Roy. Soc B, 1922, xciii, p. 449. [2] Moller,

Compten Rend. Soc. de Biol., 1922, lxxxvii, p. 759. [3] Russ, Chambers, Scott, Mottram,

Lancet , 1919, i, p. 692. [4] Bedson, Journ. Path, and Bad., 1922, xxv, pp. 400, 401. [5]

Covaerts, Co7npte8 Rcyid. Soc. de Biol., 1922, lxxxv, p. 745.

Protocol I.

Four rats, weights 120, 105, 115, 105 grm., exposed continuously for five days to
220 mgr. RaBr 3 , 2H a O, distance 8 in., screen 0*1 mm. lead plus 0*12 mm. silver ;
equivalent to 0*46 rads. Red-cell counts in millions corresponding to platelet counts
shown in fig. 1:—

Rat No. 6

7*7

8*6

7*5

7*3

Rat No. 7

10-7

9*7

Rut No. 8

7-8

8*9

Rat No. 9

8-0

8*1

9*8

Three control rats, weights 60, 70, 90 grm. Red-cell counts in millions correspond¬
ing to platelet counts :—

Rat No. 1

. 8*2

9*1

8*4

10*6

Rat No. 2

. 8*1

10*8

10*4

Rat No. 3

. 8*1

9*2

9*7

111

Platelet counts

in millions:—

Days

Rat No. 1 ...

1*05

1*38

1*31

0*90

Days

Rat No. 2 ...

1*40

1*27

1*39

Days

r f

Rat No. 3 ...

0-98

1*00

1*39

1-20

Section of Pathology

Protocol II.

Three rats, weights 60, 70, and 90 grm., exposed for one hour twice a week,
1220 mgr. RaRr^, 2 HaO, distance 8 in., screen 0*12 min. silver. Red-cell counts in
millions, corresponding to platelet counts given in fig. 3 .

Rat No. 1 ... ... 9*5 ... 10’3 ... 9*8 ... 7 8

Rat No. 2 ... ... 9*1 ... 8 7 ... 8*6

Rat No. 3 ... ... 7 8 ... 10 5 ... 8*2 ... 9 0

Protocol III.

Two rats, weights 75, 95 grm.. exposed as on Protocol II. Red-cell and platelet
counts in millions per millimetre :—

Day R.wls Platelets

Rat 75 ... ... ... 7 ... 11-3 ... 0*59

„ ... ... ... 10 ... 13*2 ... 2*02

„ . 12 ... 12*1 ... 1-65

„ 15 ... 10*8 ... 0*63

Lay Reds Platelets

Rat 95 ... ... 7 ... 9*8 ... 0*62

„ 10 ... 9*7 ... 0*61

„ ... ... 12 ... 8*8 ... 0*90

,, ... ... ... 14 ... 71 ... 0*64

Protocol IV.

Two rats, weights 70 and 60 grm. exposed as in Protocol II for one hour per week.
Platelet counts extended over eight weeks. The following figures obtained in millions
per millimetre. Time not given.

Rat 70 ... 0*7 ... 1*0 ... 0*9 ... 0*8 ... 0*9 ... 1*3 ... 11 ... 12

Rat 60 ... 0*6 .. 0 8 ... 10 ... 0*7 ... 0*7 ... 0*7 ... 10 ... 0*7

Protocol V.

Four rats, weights 95, 85, 125, 120 grm., subjected to continuous radiation.
Conditions as in Protocol I. Platelet counts in millions per millimetre.

Houru after radiation 0 2 4 24 29 48

Rat 95 0*7 ... 0 8 ... 0*9 ... 0*6 ... 0*6 ... 0*5

Hours after radiation 0 14 is 3i»

Rat 85 1*1 ... 10 ... 1*4 ... 0*8

Hours after radiation 52 7 t> 98

Rat 125 0*9 ... 1*3 ... 1*1

Hours after radiation 53 73 97

Rat 120 0*5 ... 0*5 ... 0*5

A New Fermentation Tube, in which Carbohydrates may
be separated from Proteins during Sterilization.

By Cuthbert Dukes, O.B.E., M.D., D.P.H.

(I) Object.

This fermentation tube is designed so that carbohydrates may be
separated from proteins during sterilization, preparatory to the treatment of
the fermentation of carbohydrates by bacteria in the presence of peptone.

(II) Description.

The tube consists of two parts, a stem and a cup, the cup resting on the
stem. The stem is made of medium strength, hollow glass tubing i in. in
external diameter: the stem is l£ in. long, open at the lower end and closed
at the top. The cup rests on the closed upper end of the stem, is ^ in. in
diameter, 3 in. in depth and holds just over £ c.c. The cup and the stem are

[November 21, 1922.

Dukes: A New Fermentation Tube

separated by an impermeable glass diaphragm. About 4£ c.c. of a 1 per cent,
peptone water solution containing an indicator is placed in test tubes $ in. in
diameter and 6 in. long, and the fermentation tube dropped in. i c.c. of a
10 per cent, solution of the sugar to be tested' is then delivered to the cup by
means of a pipette; the mouth of the test tube is plugged and the tubes are
autoclaved in the upright position. As with Durham's tube, the air is driven
out of the stem of the fermentation tube during sterilization and as the
temperature cools peptone water rises to take its place so that the stem fills
with fluid. Before inoculation the tube is tilted on its side and the sterilized
sugar solution runs out and mixes with the sterilized peptone water, giving a

1 per cent, concentration of the sugar in approximately 1 per cent, peptone
water. Tilting to an angle of 30 degrees is usually sufficient to ensure this
mixing, and with 6 or 8 in. test tubes there is no danger of the contained
fluids reaching the cotton-wool plug. After mixing, the tube is inoculated and
incubated ; acid production is determined from the change in the indicator;
gas production, by the displacement of the peptone water from the stem.

[A, natural size; B, C, reduced.]

fill) Reasons for the Employment of this Tube.

I designed this tube in an attempt to overcome certain difficulties
encountered in a study of the fermentation reactions of some unclassified

Section of Pathology

intestinal bacilli producing alkaline colonies on bile-salt lactose-agar plates.
I had been in the habit of sterilizing my carbohydrate and peptone solutions
together in the steamer on three successive days and used Andrade’s acid
fuchsin indicator. Three reactions noted with these organisms—and, I may
add, since observed with well-defined members of the paratyphoid group—gave
rise to perplexity, namely, a transient early acidity, a transient late acidity
and the production of a bubble of gas without acidity. By a study of the
hydrogen-ion concentration of the sugar-peptone solutions in which these
organisms were growing and by periodic quantitative estimations of the sugar
by Benedict’s method I have determined that these reactions are due, not to
the fermentation of the sugar intended to be studied, but to the fermentation
of the products to which the sugar is changed when heated in the presence of
peptone. It is common knowledge that sugars must not be autoclaved in the
presence of peptone; the very considerable change which takes place merely
on heating in the steamer is not, in my opinion, generally appreciated. When
a peptone water solution containing utilizable carbohydrate is inoculated with
an organism and incubated, two reactions proceed concurrently—an acid
fermentation from the hydrolysis of the sugar and an alkaline fermentation
from the digestion of the protein. If lactose be the sugar to be tested and this
has been steamed in the presence of peptone, a fraction of the lactose will
have been hydrolysed to glucose and other simpler substances; if the organism
under examination is a non-lactose fermenter, but capable of fermenting
glucose, it may produce sufficient acid from the glucose (appearing as the result
of steaming) to turn the indicator acid and a small bubble of gas may form,'in
spite of the fact that the lactose has not been fermented. This simple
explanation was found by chemical tests to be responsible for the troublesome
uncertainties referred to above. The particulars of these chemical tests will
be published in detail at a later date; it is sufficient to remark at present that
when the sugar solution was sterilized separately these difficulties at once
disappeared.

(IV) Advantages Claimed for New Fermentation Tube.

The danger of heating proteins and carbohydrates together has been
well-known in bacteriological work but it is doubtful whether the extent of
the alteration in the sugar has been recognized. This alteration appears
to have been responsible for the doubtful reactions sometimes recorded for
well-defined species and for the discrepancies in the results of different
investigators. Although the experienced bacteriologist may not be deceived
by these defects when working with familiar bacteria, they constitute a real
difficulty in research work on unclassified organisms. The procedure of
sterilizing the sugar solution in a separate vessel either by heat or filtration
is open to the objections that it is time-consuming, it increases the danger of
contamination and necessitates the subsequent incubation of the tubes to make
sure they are sterile. The advantages of the new fermentation tube are the
following:—

(l) That no Alteration takes place in the Sugar during Sterilization .—
Miss Masters, B.Sc., has kindly examined for me, by the polarimeter method,
some 10 per cent, lactose solutions that had stood at room temperature,
as well as others that had been steamed and also others autoclaved. She
found that no appreciable change took place as the result of autoclaving
at 120° C. for twenty minutes. On the other hand she confirmed the
pronounced deterioration suffered by the sugar when heated in the presence
of peptone. Practical experience in the use of these fermentation tubes—

Dukes: A New Fermentation Tube

seventeen different carbohydrates having been employed in testing the large
group of organisms with which I have been working—has shown that all
uncertain reactions have been eliminated.

(2) A more delicate Indicator can be employed. —I use Andrade’s acid
fuchsin. It is customary to decolorize this with normal caustic soda until
just straw coloured, but it sometimes happens with the old method that the
tubes containing peptone, sugar and indicator turn red on sterilization and
have to be discarded: to obviate this the indicator is often over-decolorized.
Since this misfortune never occurs with the tube I am describing I have been
able to use the acid fuchsin only just decolorized and thereby obtain a more
delicate indicator.

(3) The Feasibility of Autoclaving Sugar Solution. —This is a great
advantage. The less commonly employed carbohydrates are often wanted
in a hurry and by this method they are available in an hour, whereas when
sterilized in the steamer an interval of three days has to elapse. Autoclaving
also is a more certain method of sterilization than steaming,

(4) Economy. —This fermentation tube is economical when dealing with the
rare and expensive carbohydrates and by this means only the exact number of
tubes required need be prepared. The current price of xylose, inosite and
dulcite make this a most useful attribute.

(V) The Making of the Tubes.

These fermentation tubes are not difficult to make for anyone who has had
a little experience of glass-blowing. They may be made either in one piece by
closing the glass tubing which is to form the top of the stem and blowing
a bulb for the cup, or two pieces of glass of different diameter may be joined
end to end. In the former method medium-thickness glass tubing with an
external diameter of i in. is taken and cut into pieces 9 in. long, this providing
sufficient glass for two tubes. Each piece is drawn out in the middle into
a spear and then divided. The blow 7 pipe is turned on to the glass tubing
which is to form the stem 2 in. from the end and the tube revolved in the
flame until the lumen is closed. The glass immediately beyond this diaphragm
towards the spear is then heated and blown out through the open spear
into a bulb £ in. in diameter and about f in. long. When cool this elongated
bulb is filed i in. above the diaphragm and separated by applying a red hot
bead of glass.

In the second method the same sized tubing is used for the stem but the
bulb is made from medium-thickness glass tubing i in. in diameter. The bulb
piece is drawn out in the flame and the end sealed : the end of the stem piece
is heated until closed and whilst both are red hot they are joined together.
The joint is consolidated by heating and blowing at each end in turn. When
cool the cup section is cut off i in. above the diaphragm. This method
ensures that all the cups are exactly the same size. With a little experience
these tubes can he made at the rate of one every minute and a half. 1

(VI) Summary.

The foregoing describes a new fermentation tube by means of which carbo¬
hydrates may be separated from proteins during sterilization and for the
employment of which many advantages are claimed.

They ran 1 h* purchased from Baird and Tatlock, Hatton Garden, K.C.

Section of pathology.

President—Professor J. C. G. Ledingham, C.M.G., M.B., F.R.S.

The Disruptive Phenomena in Gunshot Injuries:
their Physics.

By S. G. Shattock, F.R.C.S., F.R.S.

In the Proceedings of this Section, published in 1918, 1 2 I described at length
and illustrated the chief effects produced in soft parts by gunshot, and pointed
out that, whatever peculiarities such wounds present clinically, their proper
pathological interest is limited to the fact that the velocity of the missiles
produces special effects known as explosive, or better, as disruptive. In the
present communication I propose to draw attention to the physics of the
disruptive phenomena themselves.

In considering the subject it will be simplest to commence by way of
exclusion.

(1) The Cone of Compressed Air accompanying the Bullet.

Professor Vernon Boys some years ago, as is generally known, succeeded
in photographing bullets in full flight. 1 The bullets were mostly Lee-Metford,
and the photographs were taken within a few feet of the muzzle of the rifle,
when the velocity was 2,000 ft. per second. The bullet was fired so as to
strike two leaden wires arranged almost in contact; on striking these the
missile completed the circuit of a previously arranged electric system, and the
spark so produced illuminated the photographic plate already exposed, the rifle
being discharged, of course, in the dark. The photographs (of which a selection
lately has been placed in the Royal College of Surgeons’ Museum) show that
the missile is accompanied with a conoidal wave of air, the difference in the
density of which makes its outline susceptible of photography. The summit
of the cone is rounded in correspondence with the nose of the Lee-Metford
bullet but the compressed air immediately in front of the latter does not exceed
2‘5 mm. (i in.). From this the cone spreads out somewhat obtusely around
and behind the projectile, its limit being ultimately too wide to appear in the
photographs. Furthermore, in the immediate wake of the flat base of the
bullet, and being about the same diameter as the latter, there are a series of
irregular markings indicating the disturbance in aerial density due to the filling
of the potential vacuum created by its flight.

Ar—P a l

1 Proceedings , 1918, xi (Sect. Path.), pp. 47-118.

2 Nature , March 2 and 9, 1893.

[February 20, 1923.

18 Shattock: The Disruptive Phenomena in Gunshot Injuries

How far is the cone of compressed air responsible for the explosive effect
produced upon a solid organ ? It is tempting, at first, to attribute some
importance to this, but in reality it is an absolutely negligible factor. In the
past the displacement of air by a grazing bullet and, par excellence , a common
ball was thought capable of producing considerable damage and was known as
“windage.” The results of one single method (devised by myself) of proving
how innocuous the factor is, is shown in the accompanying figure. Screens of
tissue paper, strained upon square frames of wood, 10 in. across, were shot
through at a distance of 20 ft. with a service rifle and pointed bullet. The
diameter of the hole in the paper is but little larger than that of the bullet—it
measures 1'5 cm. as against 8 mm. Its margin is radially split in a remarkably
regular way, and when the small triangular flaps, which were driven backwards,
are replaced, the aperture becomes almost closed showing how little loss of
substance has taken place owing to the pointed form of the bullet. Were the
air-wave of any import, the paper would, obviously, have been as widely torn as
the diameter of the cone of air. When the bullet is allowed to drop through

Fig. 1.—A (on the left), showing the hole produced in a tense sheet of tissue
paper, by a pointed bullet fired from a service rifle at a distance of 20 ft. The
perforation is but little larger than the diameter of the missile; proving that the air
wave produced by the bullet is a negligible factor in the explosive phenomenon. The
distance chosen, 20 ft., excludes any action of the gas of explosion. Natural size.

B, showing the aperture in the paper (after it has been soaked off the canvas
backing) produced by the pointed bullet and service rifle when fired through the
ordinary target. Natural size.

Figurae explicatio. —A, papyri charta tenuissima super frameam tensa et deinde
perforata. Apertura vix major est quam missile perforans, quo demonstratur aeris
undulam missili projectam negligi posse ut causam diruptionis quae in visceribus
compectis reperitur. Magnitudinis naturalis.

B, papvri charta crassior quam illam praecedentem. Apertura magnitudine
non exceoit missile perforans. Magnitudinis naturalis.

the tissue paper, the latter is radially split and retroverted, the hole being
exactly the diameter of the bullet. An examination of the paper targets used
at rifle ranges shows the same thing. The paper is considerably stouter than
tissue paper, and is moreover backed with canvas. The actual loss of substance
produced by the present British bullet as measured in the paper after the latter
has been soaked off the canvas is 0*4 cm. in diameter, the diameter of the bullet
being 0‘8 cm.; around this hole the paper is radially split and slightly retro¬
verted, but only for a distance that will just allow of the passage of the bullet
itself. The smaller extent of the radial splitting is of course due to the support
afforded by the canvas backing.

The lightness of the air displacement was shown in another way by
Professor Boys, by firing the bullet half an inch below a suspended sheet of
gold leaf, without the latter being deflected.

Section of Pathology

(2) The Spin of the Bullet.

The late Sir Victor Horsley, in commenting upon the effects produced by
firing unmantled cylindro-conoidal bullets (mostly miniature) at close range,
directly into soft modelling clay, attributed the resulting cavitation of the clay
chiefly to the rotation of the missile on its long axis, and in a secondary degree
only to its velocity or rate of forward movement. 1 A series of specimens
showing the result of the experiments was presented to the College museum by
this distinguished neurologist and surgeon. The types of 0‘22 ammunition
made by different manufacturers vary in power. The long ammunition, as
generally used, contains 4 to 7 gr. of powder, and the bullet weighs from 40 to
50 gr. ; under these conditions the muzzle-velocity varies from 900 to 1,300 ft.
per second. And there is a further series in the museum of University College.
Of the cavities in the clay, plaster casts were made, and with one exception,
where the clay mould is also preserved, these constitute the material for study. 2
A careful inspection of these different casts fails, in my opinion, to confirm

A B

Fig 3.—A, British bullet fired into sand at a distance of not less than 100 yds. It
shows fine parallel grooving on the apex due to the sand. The grooving presents
no appreciable obliquity or spiral.

B, British bullet flattened and split open on the side from ricochet. The fine
parallel striae on the apex run longitudinally as in the other specimen.

Figurae cxplicatio. —A, Missile Britannicuin in arenae acervum projectum, super
apicem monstraus strias minutas arenae impressas particulis. Hae striae nusquam
nisi in longitudinem directae sunt.

B, Missile Britannicuin. Super apicem monstrantur striae in longitudinem
dispositae ut in figura altera.

the evidence of any such degree of rotation as would account for the result.
Taking the results produced both by the miniature and the larger unmantled
bullets the casts show the formation of a capacious tubular cavity for about
the first half of the course of the missile. The distal portion of the cast does
not exceed in diameter that of the bullet: unlike the rest it is smooth on the
surface, and it represents the non-disruptive effects resulting when the resist¬
ance has reduced the speed of the projectile. Not infrequently the bullet turns
in this part of its course in such a way as to travel side on, but without somer¬
saulting, and is so found in situ at the end of the track. Under these circum¬
stances the corresponding part of the track is of a flattened tape-like form.
Without loading the matter w-ith needless minutiae it will be enough to select
one of these casts as typical of all.

1 The miniature bullet rotates once in 16 in., in 0 22-bore rifles as used in 1918.

2 Brit. Med. Journ ., November 21, 1914; and Proc. R. Inst., iii, 1895, p. 228.

20 Shattock: The Disruptive Phenomena in Gunshot Injuries

Fig. 2.—A photograph of a cast of one of the cavities producec
clay by firing a miniature leaden bullet into it at close range,
correspond, or course, with fissures in the clay) exhibit only small
disposition. The twist of the ritiing is one in 14 in. The bullet
lying obliquely at the end of the narrow segment of the cast. The
of Surgeons) is reduced to half the natural size.

Figurae explicatio .—E cavitate in argilla. molli causata missili
Projiciuntur striae crassires qua rum dispositione probatur missilis
posse ut diruptionis causam.

I in soft modelling
The ridges (which
traces of a spiral
can be recognized
specimen (College

proxime projecto.
rotationem negligi

Section of Pathology

On my putting the question to Professor Boys whether the ratio of forward
movement and spin would be changed on impact he thought that if the missile
proceeded side on the rotation might be relatively increased. But this com¬
plication of the question may be ignored. The rate of both movements is
increased when the missile leaves the rifle, by reason of the sudden reduction
in friction, seeing that the gas of explosion is under pressure throughout,
otherwise it would have little propulsive effect, but it may be assumed that
the ratio between the two remains the same.

Another means of estimating the rotation of the bullet after it has left the
rifle is afforded by the examination of pointed missiles fired from the service
rifle into sand. In many cases the British bullet breaks up under such cir¬
cumstances, but even then the mantle over the intact apex may give a similar
proof. A close inspection of the apex in the intact bullet will disclose fine
parallel markings or scratches due to the particles of sand. On the apex the
grooving cannot be confused with that due to the rifling, which is limited to
the broader body of the missile and coarser in kind. If there is any obliquity
in the sand-marking over the apex it is too slight to be appreciable.

(3) Velocity or Force of Impact.

The disruptive factor is thus reduced to that of forward velocity or force
of impact acting upon a mobile but practically incompressible medium. A
lateral movement is imparted to the medium from its intense compression in
front of the rapidly advancing missile, 1 while compression is also exerted
laterally since the conoidal point simultaneously acts as a wedge.

If we apply the foregoing considerations to the perforating injuries, say, of
the liver, no admission of air behind the missile takes place in the body, there
is no actual displacement of the surrounding substance as there is in the plastic
clay; and this being so the wave of force arising from the compression of the
parts in front of and at the sides of the advancing bullet results in radial
splitting. That the element of spin (once in 10 in. in the older Lee-Metford)
is a very subsidiary one, appears, also, from the short distance in which it
may have to act. In traversing the thickest part of the right lobe of the liver
from before backwards (9*7 cm., 4 in.) the bullet would make less than half
a turn; the greatest oblique diameter of the right lobe from the lower margin
upwards does not exceed 16*7 cm. (6% in.). Nevertheless, disruptive effects
are well pronounced in this viscus. In the experimental perforation of the
right lobe of the isolated and suspended sheep’s liver the thickness traversed
was 1£ in. This would give a rotation of the bullet during its passage, of
0*15 of a turn; yet the explosive result was well pronounced. 2 3 In gutter
wounds, if caused by missies at high velocity, similar rending effects ensue,
a gutter being practically a hemiperforation.

The Disruptive Phenomenon in the Skull.

It is in the skull that disruptive effects are witnessed in the highest grade.
They are limited to cases where the perforation is bilateral, and where the
missile is at high velocity. In the case of shrapnel balls the missile may per¬
forate the skull on one side and be retained within the cranial cavity or become

i The barrel of the larger present rifle is 26 in. in length, the muzzle velocity being 2,380 ft.

per second. The barrel of the shorter is 251 in., with a muzzle velocity of 2,440 ft.

3 Proceedings , 1917-18, xi (Sect. Path.), pp. 55, 56.

22 Shattock: The Disruptive Phenomena in Gunshot Injuries

embedded in the brain. But the velocity may be sufficiently high for a shrapnel
bullet to cause bilateral perforation in a thin skull without disruptive effect.
There are in the College collection thin-walled skulls from Omdurman
(Sudan war) showing these things. In gunshot perforations of the cranium of
the unilateral, low-speed kind, the perforation is accompanied with a certain
amount of Assuring around, though this may be of very limited or even
insignificant extent, and at the entry the inner plate is, of course, damaged in
excess of the outer. A still lesser degree of injury, viz., the impaction of the
missile at the stricken spot, is strikingly shown in a skull in the College col¬
lection, where a spherical musket ball projects from the back of the occipital
bone; and where by the subsequent upgrowth of osseous tissue around its base
it has become firmly and permanently fixed in position.

Whilst, finally, the minimal form of gunshot damage to the calvaria must be
assigned to a graze which produces a fracture of the internal table without
any of the outer, of which well-known condition there are examples from the
late war contained in the collection at the College. It is also established by
observation that the calvaria may be so lightly grazed as to escape any fracture
whatever, but be nevertheless so concussed that the subjacent cerebral
substance may be contused. As a curiosity there is (in the Museum of St.
Thomas’s Hospital) a femur (with a leaden bullet) which was struck at so low
a velocity that the shaft of the bone is undamaged, whilst the bullet is flattened
and fractured. When the skull is bilaterally perforated at close range, the
extent of the fracture is surprising, and has not infrequently been observed
in civil practice; for a pistol shot, if suicidal and so at close range, will
produce similar effects. When the rifle or pistol is discharged quite close to
the outside of the skull or through the mouth a second factor of damage is
introduced, viz., the gas derived from the explosion. The potency of this is
shown in cases where blank cartridge only has been used—the back of the
skull may be blown away from within the mouth. In all the experiments
superintended by myself the shooting was done at a distance of 20 ft., and
this disturbing factor eliminated.

The disruptive results in through-and-through perforations of the skull
depend upon :—

(1) The high velocity of the missile.

(2) The practical incompressibility of the semifluid cerebral substance.

(3) The rigidity of the containing envelope.

The phenomenon, though still thought by some to be hydrostatic, is really
a hydrodynamic one. It is not the result of a local compression caused by
the advancing bullet acting equally in all directions upon an incompressible
medium, confined in a completely closed and rigid space. Although the
cranium is rigid, yet owing to the ready exit of blood from the brain by
the sinuses, the actual cubic space occupied by the bullet during its perfora¬
tion of the bone and brain would be easily equalled by the displacement of
blood from the cranial cavity, and the occurrence of a proper hydrostatic
effect forestalled.

That the disruptive effect is due to a wave of displacement is brought
out by the following experiment, devised by myself, of firing at flat-sided
tins, some in the empty state, and others filled with water, but all of them
freely open at the top . The tins were 11 in. high and 7 in. across the front, and
in. across the side ; the lids, which were hinged upon a removable straight
rod of iron wire, being removed. They were shot through at a distance of
20 ft. with a service rifle and the ordinary pointed and mantled bullet.

Section of Pathology

PlG. 4.—Photograph of a cocoa tin 11 in. high and 7 in. by 5$ in. which was filled
with water and shot through at a distance of 20 ft. with a service rifle and pointed
bullet, the lid of the tin having been first removed. The aperture of entry is clean
and circular, the sides are bulged outwards, the corners being drawn in. The exit
in the back is a great rent with radially torn borders, split in large triangular flaps
which are widely everted ; a result due to the propulsion of the water against the back
accompanying the impingement of the bullet. Reduced to

Figurae expliratio .—Vas quadrilaterale ferro tenui constructum quod perforatum
est postquam aqua iinpletum est, operculo prius ablato. Apertura introitus in pariete
anteriori parva, rotunda; ilia exitiis, magna et dirupta, aqua contra parietem ilium
propulsa cum missili. Deminuitur ad $.

24 Shattock: The Disruptive Phenomena in Gunshot Injuries

That which was empty showed a clean circular aperture of entry, and a
precisely similar one of exit through the back. There is no splitting beyond
either, and the burr around the posterior margin of each hole is so little that
the result is only explicable by an equivalent amount of substance having been
shot away. The other tin was filled with water, the lid, as before mentioned,
being removed, and shot through, also at a distance of 20 ft. The aperture of
entry is clear cut, without any surrounding splitting, exactly as in the case of
the empty tin. The four sides are bulged out, the corners being drawn inwards,
so that the shape approaches that of a cylinder ; the bottom is likewise bulged
downwards. The alteration in the top which (without the lid) is furnished
with a broad flat rim, is of interest: the distal strip of the rim is
bulged upwards, whilst that in front remains flat. The exit in the back of
the tin is a great rent with radially torn borders, the metal being split in
large triangular flaps, which are widely retroverted. A true hydrostatic effect
is here out of question, since the vessel was freely open at the top. The wide
rent in the back is explained by the propulsion of the water, practically
inelastic and incompressible, 1 against it accompanying the exit of the bullet.
The rate of the wave of displacement is equal to that of the missile, and as
soon as the apex of the latter impinges against the tin the pressure of the water
splits the latter radially | from the weakened spot. The bulging upwards of
the posterior part only of the rim around the top and not of the anterior,
indicates also the main direction of the displacement. That the bulging
outwards of the sides is not due to the negative pressure brought about by
the sudden displacement and escape of water upwards is shown by the fact
that it is the four flat sides and the bottom which are bulged, whilst the more
resistant angles or corners are drawn in ; the contrary would have been the
case under the opposite condition of atmospheric pressure from without.

Corresponding results, mutatis mutandis , are obtained by firing at crania
inverted and filled with water, the foramen magnum being unclosed —an
observation which I have fully confirmed. The skulls (human) used by
myself were soaked many days in water, and then made watertight by filling
the fissures and sutures with plasticine; and in order to block the finer
vascular canals the interior was tbinly coated with plaster of Paris by
swirling round a small amount of this inside, and pouring out the excess.
They were then inverted and completely filled with water, the foramen
magnum being left open. When shot through at a distance of 20 ft. with
a service rifle and pointed bullet, they were literally blown to pieces, the
fragments being widely scattered in the neighbourhood. On replacing the
pieces so as to reconstruct the skull, much of the disruption was found to
have taken place along the lines of the sutures. In human skulls similarly
prepared, inverted and shot through in the empty state, there results a clean
circular aperture of entry and a similar one of exit.

This experiment I carried out also on sheeps , skulls which had been
partially macerated and cleaned externally, but with the dura mater left
intact, so as to close the different apertures ; the zygomatic arch of one side
was sawn away so as fully to expose the side of the'cranium, the part to be
struck being marked with a circle of black chalk. In those turned upside
down and shot through in the empty condition, two clean perforations, of entry
and exit, resulted ; there was extremely little Assuring of the thin bone around
either. In those inverted and filled with water, the foramen magnum being left

r i The slight elasticity of water connotes a certain amount of compressibility, but this is so little
that for practical purposes it may be ignored.

Section of Pathology

open , the cranium was extensively comminuted, the connexion of many of the
fragments with the rest of the skull being retained by the dura. First, a
sheep skull was shot through under similar conditions, with the brain in
situ and foramen magnum fully open. A remarkable amount of comminution
ensued.

Punctured Fractures of the Skull.

The difference in design in the outer and inner tables of the calvaria in
punctured fractures is too well known to need any description. The damage of
the table last perforated exceeds that of the table perforated first. The greater
compactness or rigidity of the internal table accentuates the difference in
perforation from without inwards as against that from within outwards. The
factor which chiefly leads to the more extensive fracture on the distal aspect
and which is so obvious that any other is often overlooked, is the want of
support on the side perforated last combined with the rigidity of the material
concerned. The result of driving a nail through a panel of wood is familiar
enough. But the following experiment upon the skull itself will be to the

A B C

Fig. 5. —Portion of an adult calvaria from which after death, a disc comprising the
external table and diploe was removed as shown in A. In (B), the internal table
was afterwards fractured from the outer aspect. Thq internal table was broken in
excess of the circular defect, as shown in (C), where the parts are viewed from the
inner aspect, proving that the excess is to be ascribed to want of support, the factor
of displacement of material in front of the perforating object being eliminated.
Natural size.

Figurae explicatio. —A, calvariae portio ab qua, post mortem resectus est discus
e tabula externa cum diploe constans, tabula interna conservata. B, tabula interna
fracta est ab extra fractura magnitudine aperturam circularem excedit quo probatur
excessum ilium ascribi insuper debere diminutione resistentiae apud tabulam postremo
perforatam. C, easdem ut ab intra apparet.

point: On portion of a normal calvaria from a young adult, and which had at no
time been allowed to dry, I trephined through the outer table and diploe ;
the bone so cut through was carefully gouged away so as to leave the inner
table intact, and smoothly exposed. The flat head of a screw just fitting the
trephine hole was placed in the latter against the inner table, and sharply
struck through. The inner table, as a result, was split in excess of the circular
aperture, into two fragments which remained hinged on as shown in the
accompanying photograph, the lateral limit of each being determined by the
presence of a meningeal groove.

The other factor can be studied separately only by experimental device:
this is the displacement of material in front of the penetrating body. In the

26 Shattock: The Disruptive Phenomena in Gunshot Injuries

following experiments, a four-sided flat-faced punch was used, the tabular bone
being perforated gradatim (with strokes of a hammer) upon a flat plate of
steel, so that the second factor—that of reduced support on the distal aspect—
was eliminated. The effect of such displacement is shown in its simplest form
when a sheet of malleable metal, such as lead, is punched upon a steel surface.
The metal, without becoming fractured, is displaced so as to rise in a low
circular eminence on the under side; the centre of the area is closed with a
thin film of the metal corresponding in area with the flat end of the punch. If
the procedure is continued still furbher, the quadrilateral film becomes detached
at its edges and broken into further fragments. The displacement of the metal
results in the production of a “ burr” around the aperture.

In the case of the calvaria, if the perforation is carried out in the way first
described, upon a resisting surface of steel, a burr is produced; but seeing that
the material is not malleable, the burr consists of displaced and tightly com¬
pressed debris of bone. The following will explain the mechanism of its
production, as carried out upon the calvaria of a child, 3 mm. in thickness,

A B

Fig. 6. —Showing the nearly complete perforation of a sheet of lead by means of a
four-sided solid punch used against a flat surface of steel. The displacement of the
malleable metal has led to the formation of a circular “burr”; a thin quadrilateral
film of metal still remains intact. A, as seen from the lower aspect. B, in vertical
section. Twice the natural size.

Figurae explicatio .—Plumbi lamina quae clavo perforata est, tabulam super
ferream. Monstratur eminentia circularis aspectu inferiori, plumbi expressioni sine
fractura causata. In media eminentia lamella quadrata aperturara aahuc obturat.
A, Ut apparet ab infra. B, in sectione verticali. Figurae bis magnificantur.

and which had at no time been allowed to dry. The four-sided, flat-faced
punch was driven from the inner aspect outwards, so that the table last
perforated should be fully supported against the flat surface of steel under¬
neath. In the process of penetration there is first produced on the lower side,
a circular elevation, the outer table over which is intact. If the parts are
examined at this stage by means of a vertical section, after the bone has been
dehydrated in alcohol, passed through xylol, and embedded in paraffin, a quadri¬
lateral segment of the outer table is found driven forwards, and the sub¬
jacent diploe crushed. As the penetration proceeds the elevation increases,
and the external table over it becomes radially fissured. Finally the eminence
becomes broken into small fragments, the “burr” so produced consisting
superficially of minute pieces of the outer table, some of them still hinged on,
and more deeply, of displaced fragments of the diploe and internal table. But

Section of Pathology

E F

J.R.FORU o

Fig. 7.—Showing stages in the perforation of the calvaria of a child, by means of a
solid four-sided flat-ended punch, the bone being supported upon a flat plate of steel.
A, B, C, D, are viewed from the lower aspect; E, F, in vertical section. The punch
was driven from the inner table outwards.

A. —The formation of a low hemispherical swelling due to the displacement and
compression of the inner table and diploe.

B. —The outer table radially split over the eminence.

C. —Perforation complete, showing the local eminence or burr, formed superficially
of everted fragments of the outer table, the debris closing the hole being displaced by
the forward movement of the punch.

D. —The burr removed by pressing a scalpel against the four sides of the punch ;
the circle marks the amount of loss due to the removal of the burr. This loss is quite
local, there being no further fracture due to the want of support which obtains under
natural conditions, as the punch was used against a flat surface of steel.

E. —Vertical section ; tne punch about halfway through; showing the displacement
of a piece of the internal table, and compression of the diploe.

F. —Vertical section ; complete perforation ; showing fracture of the outer table
and its eversion, with displacement of the debris above ; so as to form a burr.

All the figures are enlarged twice.

Figurae explication— Monstrantur gradus in calvaria pueri post mortem perforanda.
Perforata est calvaria tabulam super ferream, clavo percusso contra laminam cranii
in tern am.

A. —Gradus primus. Eminentia circularis apud laminam ossis externam, com-
pressione laminae internae atque diploiedis causata.

B. —Gradus secundus. Eminentia eadem, lamina externa in radios fissa.

C. —Gradus tertius. Perforatio laminae completa; laminae externae fragmenta
eversa juxta aperturam.

D. —Perforatio completa ; ossis fragmentorum eversorum, circulo absciso.

E. —Sectio verticalis. Perforatio incompleta. Monstrans eminentiam circularem
comprcssione laminae internae atque diploiedis causatam.

F. —Sectio verticalis ; annulum fragmentorum laminae externae atque diploiedis
circum aperturam monstrans.

In his omnibus casibus, calvaria tabulam super ferream resistentein perforata,
fractura ad marginem perforationis limitatur.

Bis magnificantur omnes figurae.

28 Shattock: The Disruptive Phenomena in Gunshot Injuries

there is no splitting of the external table beyond the burr, owing to the support
afforded by the steel surface beneath the bone. When the burr is removed by
pressing a scalpel horizontally against the sides of the punch, the osseous
d6bris around the latter is found compactly pressed together, the Joss of
substance in the external table being circumscribed by a subcircular line corre¬
sponding with the limit of the burr. On pushing the punch completely through,
the central part of the debris is displaced and the opening cleared. The
aperture in the internal table, i.e., of entry, remains perfectly sharp, and
without surrounding fissure : no escape of material takes place backwards, i.e.,
behind the punch. As applied to punctured fractures of the calvaria occurring
under natural conditions, however, the displacement of material in front of the
penetrating instrument is a factor of minor importance in producing the dis¬
parity of damage on the two aspects of the bone : for the puncture cannot take
place against a resisting surface like that furnished under the conditions of the
experiment. The factor is overshadowed by that of the want of support on
the aspect last perforated.

Gunshot Fractures of Long: Bones.

The pathological interest attaching to gunshot fractures of the long bones
is so small that it is not worth taking up. It will be enough to point out one
thing, viz., that a new element is introduced, which is the rigidity of the
structure damaged; though the same rule holds good elsewhere—the greater
the velocity of the missile, the greater the damage. In the accompanying
photograph is shown the splitting produced in a tibia by slowly compressing
a limited part of its shaft in a parallel vice : the bone used had not been at any
time allowed to dry, and its brittleness in this way increased. The longitudinal
direction of the main fissures is determined by the “ grain ” of the bone due to
the direction of the Haversian canals: the fissures tend to run in the planes
of least resistance.

In compact tissue, the local comminution, apart from the distant Assuring,
is very pronounced if the shaft is fairly struck at close range. This is well
shown in some of Sir Victor Horsley’s experiments (now in University College
Museum), where the shafts of the tibia and of the femur of a dead pony were
shot point blank. In the tibia the bone at the stricken spot is broken into
fragments so numerous and small that it looks as if roughly powdered, and
from this fissures extend for considerable distances in both directions;
and much the same has happened in the femur. The result is somewhat
comparable to that obtained by Professor Boys on firing through a sheet of
plate glass, where the photograph shows a column of glass dust accompanying
and concealing the Lee-Metford bullet after its perforation. The lateral and
forward displacement of fragments around the advancing missile necessarily
results in an increased amount of damage to the soft parts of a limb. Short of
a stereoscopic skiagram, a good method of displaying the true state of things
is that of laying open the limb through the seat of fracture, or after being
hardened in Kaiserling fluid, the soft parts may be cut away from one side
and the fragments embedded in the muscles displayed individually. 1 But for
displaying the actual damage and secondary fissures, many of which would
otherwise escape detection, the time-honoured method of maceration retains
its value. The forcible displacement of such fragments into the muscles is
an important factor in producing the protrusion of the latter through the
cutaneous exit, which under such circumstances may be extensively split.

1 See figure 12 at end of paper.

Section of Pathology

Fig. 8.—The upper half of a tibia which was slowly compressed in a vice, over the
area indicated by the V line. The shaft is extensively split, some of the fissures
reaching far from the spot compressed. Reduced.

Figurae cxplicatio .—Tibiae nars superior quae in machina compressa est apud
locum lineis indicatum : ossis diaphysis late comminuitur, fissuris extendentious
longe a loco compresso. Deminuitur.

The British Rifle Bullet.

It has been stated 1 that the British bullet, in consequence of the pointed
end of the cone being of aluminium, and the rest of lead, has an explosive
action ; that on striking (bone at least) the momentum of the softer metal
would carry this forwards upon the aluminium, and split up the mantle,
seeing that the two segments of the core are discontinuous. It is next to
impossible to estimate the relative vulnerability of the British and German
bullets with accuracy from their examination when taken from the wounded,
since ricochet, the striking of the missile against accoutrement, gas masks, &c.,
furnish such abundant sources of damage to them.

The following experiments show that it is only on meeting with a high

i Professor Dr. K. Stargardt, Munch, mcd. Wochcnsc.hr ., 1914, lxi, p. 2448.

30 Shattock: The Disruptive Phenomena in Gunshot Injuries

resistance that the British bullet undergoes fragmentation. 1 They were made
by firing through bone with a service rifle and pointed bullet at a distance of
20 ft., into cotton waste. In order to get a direct hit I selected well-
developed adult sterna, which had not been allowed to dry after removal
from the body ; and for denser bone the calvaria. A sternum was screwed by
the ends, over an aperture in the front of a long box: behind the aperture was
placed a cylindrical sack about 2 ft. in length, tightly packed with cotton-waste,
beyond which it was first ascertained that the bullet would penetrate; behind
the sack the box was filled with a mass of loose waste, in which the missile
was effectively stopped without striking any second object.

(1) A sternum was shot through exactly in the middle of the gladiolus at
20 ft. The bullet recovered from the loose cotton waste was quite undamaged.

(2) Two other sterna were then closely spliced together, and shot through
exactly in the mid-line. The bullet on recovery was, as in the first case,
absolutely intact.

Fig. 9.—A, British bullet fired at a distance of 20 ft., through a parietal bone of
medium thickness (0*6 cm.) : the missile is intact.

B, British bullet fired through a thicker and denser parietal bone (0*9 c.m.), and
received, like the foregoing, into cotton waste. The mantle at the base is longi¬
tudinally split and everted ; the lead and aluminium cone have been evacuated.
Natural size.

Fif/urac explication —A, missile Britannicum, quod os parietale, in crassitudine
(0‘6 cm.) perforaverat missile intactus eat.

B, missile Britannicum quod os parietale crassius atque densius quam praecedens
perforaverat (0*0 c.m.). Apud basem missilis cortex in longitudinem scissus et
eversus est, plumbo ab intra expanso. Magnitudinis naturalis.

In order to test the effect upon more resistant bone, a similar experiment
was carried out upon the parietal bones of two human calvariae. One of these
from a male, aged 56, measured, where perforated, 0*6 cm. in thickness, and was
a fair sample of an ordinary male skull; the other measured 0*9 cm., and,
without being diseased, was of high density, the tables being thick and the
diploe close. They had at no time been allowed to dry after removal from

1 The* arrangements for carrying out these and other experiments were kindly made for me at
the Acton range ; and at the Polytechnic Institution (21 st Battalion, County of London Volunteers
Begiment: Oliicer Commanding, Major .T. E. K. Studd) : Staff Sergeant David Pool, an expert
marksman, who did the shooting with unfailing accuracy.

Section of Pathology

the body. The portion shot through was the flatter area, the bone being
turned with the internal surface forwards. The bones were cleanly perforated
at right angles to the surface, at a distance of 20 ft., the bullets being recovered
from the cotton waste, through which no previous or subsequent shooting had
been carried out. In the thinner calvaria the entry in the inner table was
sharp, circular, of the exact diameter of the bullet; the bone around the exit
was comminuted and shot away for a circular area 1‘5 cm. in diameter.
The bullet was quite undamaged except for a slight flattening of its apex.
In the case of the thicker calvaria, the actual perforation was slightly larger
than the bullet, and not geometrically circular. The inner table around the
entry was comminuted and wasting over an area about 1*5 cm. in diameter.
On the opposite aspect, the comminution and loss around the perforation
extended over an area about 2*5 cm. in diameter. The bullet: the base of the
mantle is split as far as the second of its transverse grooves (1 cm.) and everted;
the aluminium cone and lead are evacuated.

Not to labour the matter, it is clear that the basal expansion and splitting of
the mouth have occurred on striking (the apex of the bullet is flattened) and

Fig. 10.—A, section of British bullet, showing early expansion or mushrooming of
the lead at its base and a resulting uniform recurvation of the free edge of the mantle,
without actual splitting. The accurate flattening of the apex shows that a direct hit
w'as made. From the seat of w f ar in France.

B, a British bullet of winch the mantle is deeply split and recurved from the base
towards the apex. The apex is accurately flattened showing that a direct hit was
made. From the seat of W'ar in France.

Figurae explicatio .—A, Missile Britannicum cujus cortex apud basem recurvatum
sine scissuris est, plumbo expanso. Gradus diruptionis primus.

B, Missile Britannicum cujus cortex apud basem value in longitudinem scissa est.
Magnitudinis naturalis.

not after perforation, since the distorted mantle accurately fits the irregular
entry and can only L be passed through by manoeuvring the missile, with a
slight obliquity.

Is the Leaden Core Fluid when the Bullet leaves the Rifle ?

That the older leaden British unmantled bullet, as fired from the Martini-
Henry rifle, did not soften in its flight was shown by the fact that after being
fired at steel targets, the base remained intact and with it the circular groove
close above, the rest becoming mushroomed and fractured. But of the modern,
high-velocity, mantled missile, it has been stated that at the time it leaves the

32 Shattock: The Disruptive Phenomena in Gunshot Injuries

rifle the lead is in a molten state, from the heat generated by the rifling and
that of the explosive acting directly upon it. This assertion has been as con¬
fidently denied.

The question is of sufficient interest to make it worth inquiry. The parti¬
cular method devised by myself was as follows: The service bullet was removed
from its cartridge; this can be done by placing the latter in a vice, tapping
the point of the bullet with a hammer so as to drive it behind and obliterate
the indented parts of the cartridge which hold it in position, and then with¬
drawing it from behind forwards. The bullets used were of American make,
in every way like the British except that there were two circular grooves
towards the base instead of one ; the exposed lead was stamped in low relief,
XJ S. Into the centre of the lead a short channel was clearly drilled out 0'5
cm. in length. The bullet was replaced in its cartridge, and fired, at a distance
of 20 ft. directly into the box of cotton waste, from which it was afterwards
recovered. Were the lead at any moment molten, the drilled channel would,
of course, become obliterated. On filing the bullets from the side, the channel
was found quite unobliterated. Although it is clear that the lead is at no
moment molten throughout, there is nevertheless sufficient heat generated by the
explosion to melt the face of the core exposed at the base. This appears from
the fact that the raised letters U S in the base of the unfired bullet, are invariably
found obliterated when the missile is recovered in the intact state from cotton
waste. The pressure within the barrel is one expressed not in pounds but in
tons ; but seeing that this would be equal at every point upon the base of the lead
the stamp would not be obliterated from this cause alone. The melting point
of lead is 377°C. : the heat generated by the explosive now used, viz., cordite, is
about 4,000°C.; and the metal being a bad conductor of heat, its exposed surface
is melted without the whole mass.

Effects of Compression upon the British Bullet .

The following observations were made to see whether “ expansion M at the
junction of the aluminium and leaden portions of the core resulted from
compression:—

(1) A bullet was placed in a powerful parallel vice, i.e., one in which the
jaws approach in a perfectly parallel direction, and slowly compressed from
side to side until quite flattened. No splitting of the mantle occurred either
longitudinally or transversely at the junction of the aluminium and lead of the
core; a considerable amount of the lead was expressed through the open base.

(2) A bullet was placed obliquely from point to base at an angle of 45°.
Under pressure the point and base became flattened obliquely to the proper
axis of the bullet, but without any splitting of the mantle or distortion occur-
ing elsewhere.

(3) A bullet was compressed directly, point to base, the egress of the lead
from the base being in this way quite prevented. After slight flattening of the
point and base it began to curve ; the compression was carried on until the
curve had almost reached a semicircle. No splitting of the mantle occurred ;
and no lateral protrusion of the included lead at the line of its junction with
the aluminium cone. This observation was repeated with precisely the same
result. The longitudinal section made of one of the last two showed that
no lateral expansion of the lead upon the aluminium had taken place, the
deformity being due to flexion of the lead and invagination of the otherwise
intact mantle on the concave side.

Section of Pathology

To sum up: Although the British bullet is not designed (like the Jeffrey 1 )
to expand—the aluminium being used in order to carry the centre of gravity
nearer to the base and reduce oscillation in flight; nevertheless the want of
continuity between the two parts of the core theoretically weakens the bullet
at the plane of apposition. Point to base compression, however, is not
accompanied with mushrooming of the lead over the harder aluminium cone
and splitting of the mantle at this spot. The bending which is started by
slight deviation in the axis, proceeds, without splitting of the mantle, and
extrusion of the core taking place even when the curvature is carried to a
semicircle. Nevertheless, it must be admitted that a certain amount of
vulnerability results from the fact that the British mantle is of ductile copper-
nickel alloy and not of steel. The thickness of the British mantle is 0*5 mm. ;
that of the German (steel, plated with nickel), 0’7 mm.; in the latter, too,
the amount turned in over the base of the lead is slightly greater. The
diameter of the two missiles is identical. The difference in the resistance of
the two mantles, I was able to show by having the weight which was necessary
to start their splaying out, measured. Two equal lengths were tested after
extraction of the core (no heat being used for this purpose). A steel ball
15 in. in diameter was placed on the opened end of each of the two mantles :

Fig. 11.—E, British bullet pressed flat in a parallel vice. No protrusion of the leaden
core and splitting of the mantle have occurred over the site of the aluminium cone.
Some of the lead is expressed from the open end of the mantle. G, British bullet corn-
pressed from point to base until curved to a semicircle. H, Section of the same; no
protrusion of the lead over the aluminium has taken place, nor splitting of the mantle.
F, British bullet compressed from point to base at an angle of 45®. Nodistortion at the
junction of the aluminium and the leaden core has resulted.

Figurae explicatio .—Missilia Britannica in machina, compressa. Deformantur
omnia sine fractura. E, missile a latere compressum. F, oblique. G, in axe
vertical!. H, sectio verticalis missilia. (G) aluminii conus intactus, et cortex in
plumbum involutus.

the British bullet had not been fired, the German had. The load was increased
11 lb. at a time. The British mantle began to yield under a load of 180 lb.;
the German mantle, under a load of 390 lb.

What happens in the case of the British rifle bullet is, that on direct
impact against a high resistance, the comparative weakness of the mantle
allows the lead to splay out, and to split the mantle at its free edge over the
open base. Thence the splitting may extend, the strips being curved outwards
and displaced towards the apex, somewhat like the sepals of a fuchsia. The
actual lines of fissure may be started by the grooves in the mantle due to the
rifling. The percussion of the loosened lead against the harder aluminium may
then lead to the expulsion of the former through the widely open base of the
mantle. The expansion in a word, takes place, not apically, but basally.

1 In this bullet the mantle is split in a series of longitudinal lines between the apex and base,
K’bich the momentum of the leaden core opens out on the missile striking.

Fig. 12.—A dissection of the thigh made after hardening of the parts in Kaiserling
solution, showing the displacement of the fragments of a comminuted gunshot fracture
of the femur, into the surrounding muscles. From a preparation by Mr. C. F. Beadles,
in the National War Collection in the Koval College of Surgeons.

Figurae explicatio .—Cruris dissectio, telis prius induratis, monstrans femoris
fragmentorum dislocationem in musculos circumjacentes missili causa tain.

Section of pathology

President—Professor J. C. G. Ledingham, C.M.G., M.B., F.B.S.

On the Inheritance of the Specific Isoagglutinable Substances

of Human Red Cells.

By S. C. Dyke, M.B., B.Ch., D.P.H.Oxon., and
C. H. Budge, M.R.C.S., L.R.C.P.

(From the Pathological Laboratory of the Clinical Units , St. Thomas's Hospital.)

With a Note on the Possible Existence of a Lethal Factor.

By S. C. Dyke.

The observations forming the basis of the present paper were under¬
taken with the view of testing the hypothesis formulated by von Dungem
and Hirsohfeld (1910) [1] as to the inheritance of the specific agglutinable
properties A and B, the presence of which in, or absence from, the human
red cells determines the blood group of the individual. The authors made
observations on 384 individuals, constituting seventy-two families, and came
to the conclusion that the properties A and B can never appear in the
offspring without having been present in at least one of the parents, and
furthermore that, when inherited, these properties appear in the offspring in
accordance with recognized Mendelian laws.

Historical.

The fact that all of a series of bloods observed by him might be divided
into groups according to the interaction of their sera and corpuscles was
demonstrated by Landsteiner (1901) [2]. He described three groups
corresponding to what are now known in this country as Groups II, III, and
IV. Group I, being rare, was not encountered by him. To account for these
groups he pointed out that it was necessary to postulate only two agglutinable
properties in the corpuscles, which he called A and B , and two corresponding
agglutinins in the serum, which may be designated a and b , though these
designations were not used by Landsteiner. His three groups then would have

their constitutions as follows :—

Corpuscles

Serum

Group II

Group III

Group IV

a and b

My—Pa 1

Dyke and Budge: Human Bed Cells

Landsteiner observed that the blood group of a child might be quite different
from that of its mother.

Decastello and Sturli (1902) [3] confirmed these findings, but found
four persons in their series of 155 who fell into none of Landsteiner* s
three groups. From the paper it is obvious that these four persons
belonged to what is now known in this country as Group I, but the
significance of their observations was not appreciated by these workers.
They were the first to demonstrate by absorption tests the correctness of
Landsteiner’s hypothesis so far as the three then recognized groups were
concerned.

It was not until another five years had elapsed that the significance of
Decastello and Sturli’s four unplaced individuals was recognized by Jansky
(1907) [4]. In a series of his own, he met with similar bloods which could
be allocated to none of Landsteiner’s three groups, and recognized that in them
he was dealing with blood of the constitution—

Corpuscles A and B. Serum 0.

This group he described as No. IY. Since his time no further type of blood
has been observed, and it would seem, on the present evidence, that the blood
of all human beings falls into one of the four groups which Jansky described

as follows:—

Corpuscles Serum

Group I ... ... ... ... O ... ... a and b

Group II ... .. ... ... A ... ... b

Group III ... ... ... ... B ... ... a

Group IV ... ... ... ... ^4 and B ... ... O

This classification places as Group I what is usually known in this country
as Group IV and vice versa. This is due to the fact that here the nomen¬
clature adopted by Moss (1910) [5] is still in vogue. Moss recognized the
four groups of blood independently of Jansky, but explained their constitution
in a different manner.

Moss’s hypothesis postulates three agglutinable substances in the cor¬
puscles and three corresponding agglutinins in the serum. It may be expressed

schematically as follows :—

Corpuscles

Serum

Group I

. A. B y C ...

—

Group II

. B , C

Group III

. A, C

Group IV

—

Moss’s suggestion is, on the face of things, as good an explanation of the
interaction of the corpuscles and sera of the various groups as that of Land¬
steiner. The readiest means of ascertaining which of the two suggestions is
correct is by the absorption of the agglutinins of the sera by their appropriate
corpuscles. The test case is that of Group I (Jansky), IV (Moss). According
to Landsteiner and Jansky serum of this group should contain the agglutinins
a and b; absorption of this serum by corpuscles of Group II bearing the
agglutinable substance A , or of Group III bearing the substance B t should in
each case leave one agglutinin behind ; in the first case 6, and in the second a,
while absorption by corpuscles of Group I (Moss), IV (Jansky), bearing both
agglutinable substances A and B should remove all agglutinins. According
to Moss’s schema, all the agglutinin c should be removed from serum of
Group IV (Moss), I (Jansky) by absorption either by corpuscles of Group I
{ABC), II (B C), or III (A C).

Section of Pathology

Experiments by Hektoen (1907) [6], Koeckert (1920) [7], Schfitze (1921)
[8] and Dyke (1922) [9] have amply confirmed for this and all other cases
the correctness of the view of Landsteiner and Jansky as to the constitution
of the groups. Although Jansky's classification has the priority, that of
Moss has hitherto been in use in this country, and has been used by one
of us (Dyke) [9], [10], [15] in previous communications. It is accordingly
retained in this paper.

From what has been said above it is evident that in their appearance in
the blood, the agglutinable properties A and B and their respective agglutinins
a and b behave as reciprocals. When A alone is present in the cor¬
puscles b alone appears in the serum, as in a Group II blood; when B
appears in the corpuscles, a is present in the serum, and the result is a
blood of Group III; when both A and B are present in the corpuscles, as
in Group I, neither agglutinin appears in the serum: and when both are
absent from the corpuscles, as in Group IV, both agglutinins appear in the
serum.

Rationale op Grouping Tests.

On these facts is based the method of determining the presence or absence
of the agglutinable properties A and B of the corpuscles, and consequently
the blood groups, in any case. For this purpose sera of known Groups II
and III only are required. Since serum of Group II bears the agglutinin
a and that of III b , it follows from the above that corpuscles of Group I
will be agglutinated by both the II and III sera; those of Group II by
the III serum only ; those of Group III by the II serum only, and those
of Group IY by neither. Certain details as to the actual technique are
given below.

The Factors in Inheritance.

Von Dungern and Hirschfeld, on studying the inheritance of Landsteiner’s
agglutinable properties A and B , found that they never appeared in the
offspring without having been present in the parents. On their evidence they
concluded that they behaved as Mendelian dominants. As in the case of
Mendel's sweet peas, the dominant Long formed one half of an allelomorphic
pair with the recessive Not-Long or Short, so they concluded that A and B
constituted each one half of an allelomorphic pair, of which the other halves
were Not-A and Not-B. But they pointed out that Not-^4 and Not-B are
not negative qualities but, on the contrary, are represented by the reciprocal
agglutinins of the serum, called by them a and /?, but referred to hereafter as
a and b. Thus, as in the case of Mendel's sweet peas, an individual showing
the dominant Long might still bear, hidden in its gametic complex, the recessive
Short, and might thus have short offspring, so an individual showing the
dominant A (Group II) might still bear, hidden in his or her gametic constitu¬
tion, the recessive a; if present in such an individual, this would not be
expressed in his serum, but might appear in the offspring.

For a full understanding of this point, it is necessary to bear in mind the
difference between an individual and a gamete. A Group II individual has
the formula Corpuscles A, Serum b. Granted that this individual is of a pure
race or homozygous, segregation of the factors in the production of the gametes
will proceed in such a way as to produce gametes of the formula Ah only.
Supposing, however, that the individual is not homozygous, but hybrid or
heterozygous, then the recessive b will be present but masked in the individual

Dyke and Budge: Human Bed Cells

by the dominant A . The expressed formula of such an individual will be Ab,
but the actual formula will be Ab(a), and in formation of the gametes segrega¬
tion will take place in such a way as to produce gametes of the formula Ah and
ab. Matings of two such Group II individuals may give rise to zygotes of the
formula Ab Ab (homozygous Group II), Abab (heterozygous Group II) or abab
(Group IV).

Learmonth (1920) [ll] made observations on 180 individuals belonging
to forty families, and found only one exception to von Dungern and Hirsch-
feld*s hypothesis. Learmonth, in accordance with usage of workers on
heredity, designated the dominant agglutinable properties A and B and their
allelomorphic recessives a and b, this being the nomenclature adopted in the
present paper.

Further confirmatory evidence has been produced by Ottenburg (1921-2)
[12] [13] in America.

Authors* Data.

The observations forming the basis of the present communication were
made upon material provided by the maternity ward of St. Thomas's Hospital.
With the co-operation of the nursing staff, blood was collected from the
umbilical cords of infants at birth and used for ascertaining the group of the
child. Corpuscles for the same purpose were obtained from the mothers as
they lay in the wards, and from the fathers on their visits. In this way
observations were conducted upon both parents and offspring in ninety-eight
cases.

The blood for ascertaining the groups of the infants was collected in a test
tube and allowed to clot. The serum was then pipetted off and the corpuscles
washed three times in a 2 per cent, sodium citrate solution in normal saline.
Blood was obtained from the parents by finger puncture, the drop being collected
in similar citrate solution. The serum of the parents was not tested, the group
being determined by the reaction of the corpuscles alone.

The actual grouping tests were performed, with slight modifications, in the
manner already described by one of us (Dyke [9], [15]). This involves
making a dilution of approximately 1 in 200 of a 50 per cent, corpuscular
emulsion in the saline citrate solution and mixing one drop of this with one
drop of the serum against which the corpuscles are to be tested. A cover-
glass preparation is made from this corpuscle serum mixture and examined
under the low power of the microscope. No originality is claimed for this
technique, but it is believed to give infinitely finer and more clear-cut results
than the macroscopic method. The data collected in the present investiga¬
tion are detailed below (p. 39).

Constitution of Blood at Birth.

Many writers have pointed out that while the agglutinable properties may
be demonstrated in the corpuscles of infants at birth, the reciprocal agglutinins
may be absent for some months. This is quite evident in the data given in the
above table. Of the thirty-seven babies in the series identified by the reaction
of their corpuscles as belonging either to Group II or III, only nine, or about
twenty-five per cent., had demonstrable agglutinins in their serum which
would have made it possible, by evidence derived from that source alone, to
allocate them to their proper groups. Of the fifty-nine babies whose corpuscles
were agglutinable by either Group II or III serum, and which were consequently

Section of Pathology

Table I.

Placental Blood

Red cell* Seram

Case

uumber

Father

Group

Mother

-f Serum

4 Serum

III

4 Red cells 4 Red cells
II III

Mating Type I 4- II.

—

Mating Type I 4 IV.

+ ••• ~

—

:*8

Mating Type II 4* !!•

— ... 4

—

100

—

103

—

115

—

122

—

125

—

132

—

134

... —

—

137

—

III

Mating Type II 4- HI-

III

—

III

—

III

—

138

III

—

Mating Type II 4 IV*

—

... f-

—

... 4

—

...

—

- -

—

■*-

—

... f

—

101

—

105

—

107

—

108

—

109

—

113

—

116

—

...

120

—

■f

£ ' £4 -- 0 .

123

—

124

—

126

—

129

—

133

—

Baby’*

group

III

III
1

IV
II

Dyke and Budge: Human Red Cells

Table I — Continued.

Placental Blood

Group

Red cells

Serum

Cane

number

Father

Mother

4 Serum 4 Serum
II III

... Ill

Mating Type III -4

... Ill

1 • • •

-t ... —

III

... IV

... Ill

4 ... —

... Ill

— ... —

... Ill

4- ... —

III

... IV

— ... —

... Ill

4- ... —

112

III

... IV

4 ... —

114

III

... IV

4- ... —

118

III

... IV

— ... —

135

III

... IV

r ... —

... IV

Mating Type IV 4-

... IV

— ... _

... IV

— ... —

... IV

— ... —

... IV

— ... —

... IV

— ... —

... IV

— ... —

... IV

— ... —

... IV

— ... —

... IV

— ... —

... IV

— ... —

... IV

— ... —

... IV

— ... —

... TV

— ... —

... IV

— .. —

... IV

—

— ... —

... IV

— ... —

—

... IV

— ... —

... IV

— ... —

... IV

— ... —

... IV

— ... —

117

... IV

— ... —

119

... IV

— ... —

121

... IV

— ... —

127

... IV

—

131

... IV

—

4 Red cells 4 Red cells

* Twins, binovnlar.

III

Baby k
group

IV*

III

IV
III
III

III

placed in Group IV, only nine, or about 15 per cent., showed both agglutinins
a and b in their serum, while ten showed only one of the agglutinins—in four
cases a and in six cases b —instead of the two which should theoretically be
present in the serum of a Group IV individual.

Whether or not it is justifiable to allocate bloods to groups on the evidence
of the corpuscles alone is open to doubt. Happ (1920) [14], who investigated
the blood of a number of children at birth and later in life, states definitely
that changes may occur not only as the result of the appearance of agglutinins
absent from the serum at birth, but also from the appearance of either or both
agglutinable substances absent from the corpuscles earlier in life. This matter
requires further investigation, but does not affect the thesis of von Dungem

AND BUEKJE

Section of Pathology

Grand Total ... Unions, 213; Offspring, 328.

Dyke and Budge: Human Bed Cells

and Hirschfeld that the agglutinable substances A and B cannot appear in the
offspring unless present in the parents. This question and its medico-legal
bearing has been discussed elsewhere by one of us (Dyke [15]).

The present data are summarized and compared with those of Learmonth
and Ottenburg below.

The above table shows the results of observations on 213 married couples
and 323 of their offspring. In every instance except one there is no appearance
of the A or B properties in the offspring without their having been present in
the parents. The one exception occurs in Learmonth’s series and is marked
with an asterisk in the table above. In such a large series one illegitimate
offspring can hardly be regarded as constituting a large proportion of the total.
The experimental method is obviously inapplicable to an investigation such
as the present, and such conclusions as can be drawn must be arrived at by
deduction. This being so, the figures given above seem to offer reasonable
ground for the acceptance of von Dungern and Hirschfeld's hypothesis.

Mode of Inheritance of Groups.

In considering to what group the offspring of any two parents must
belong, it must be remembered that it is not the group which is inherited.
The dominants A and B and the recessives a and b are the inheritable factors
and it is on the presence or absence of these that the blood group depends.
For all groups, except Group IV, two or more genetic constitutions are
theoretically possible and in determining to what group the offspring of any
given parents may belong all the constitutions must be taken into account.

These possible constitutions are as follows :—

For Group I ... AB AB, AB ab , AB aB , AB Ab

,, II ... Ab Ab (homozygous), Ab ab (heterozygous)

,, III ... Ba Ba (homozygous), Ba ab (heterozygous)

,, IV ... ab ab (double recessive)

The constitution of the offspring will depend upon that of the parents.
So far as groups alone are concerned, ten types of mating are possible, but it
is evident from the table of possible constitutions given above, that within all
those types, with the exception of IV -f IV, many possibilities exist. These
possibilities are summarized below:—

(1) I + I. The offspring may belong, according to the constitution of the
parent and the manner in which segregation of the factors has occurred, to
any one of the four groups, either I (AB ab , AB AB , AB aB or AB Ab ),
II (Ab Ab ov Ab ab ), III (Ba Ba or Ba ab ), or IV (ab ab).

(2) I + II. Here again the offspring may belong to any of the four
groups. Leaving aside the possibilities under Group I, the only difference
from (1) is that although a heterozygous Group III individual may result,
it is impossible for the offspring to be homozygous Group III as in (l).
As pointed out above, however, practically, homozygous individuals are
indistinguishable from heterozygous.

(3) I + III. As in (1) offspring of all groups may occur, the only
difference, leaving aside the possibilities under Group I, being that offspring
belonging to Group II can only be heterozygous.

(4) I + IV. Again, as in (l) all possible groups may occur in the off¬
spring, the only differences, leaving aside those under Group I, being that
offspring belonging to Group II or III must be heterozygous.

The full possibilities of the constitution of Group I offspring have not been
gone into, in considering the above four types of mating, since they are so

Section of Pathology

numerous and since moreover there is some evidence that only one type
of constitution actually occurs.

(5) II + II. Offspring must be either Group II (Ab Ab or Ab ab) or
IY (ab ab).

(6) II + III. Offspring may be of any group and of any constitution
except homozygous Group II or III.

(7) II + IV. Offspring must be either heterozygous Group II (Ab ab ),
or Group IV (ab ab).

(8) III + III. Offspring must be either of Group III—homozygous
(Ba Ba) or heterozygous (Ba ab ), or of Group IV (ab ab).

(9) III -i- IV. This mating can only result in offspring of heterozygous
Group III (Ba ab) or of Group IV (ab ab).

(10) IV + IV. Both parents in this type of mating are double recessives ;
no dominant is present in them and such cannot appear in the offspring.
Children of two Group IV parents can then only be of Group IV (ab ab).

The above considerations are summarized below :—

Table III.

Offspring can be of
groups

. I, II, III, or IV

II, or IV only

. I, II, III, or IV

II, or IV only

. Ill, or IV only

. IV only

Conclusions.

(1) The agglutinable properties A and B are demonstrable in the blood of
the newborn.

(2) These properties A and B in the genetic behaviour are dominants.

(3) The agglutinins a and b are in their genetic behaviour recessives.

(4) The properties A and B cannot appear in the blood of the offspring
without having been present in the blood of the parents.

The thanks of the authors are due to Dr. J. S. Fairbairn, of St. Thomas’s
Hospital, for giving access to the maternity wards of the hospital; to the
Sister and Nursing Staff of Mary Ward, St. Thomas’s Hospital, for their
kindness in collecting with all the necessary care over 150 samples of placental
blood; to Miss M. Robertson, of the Lister Institute, for valuable advice and
suggestions; and to the Medical Research Council, without whose assistance
the work could not have been carried out.

A NOTE ON THE POSSIBLE EXISTENCE OF A LETHAL FACTOR.

By S. C. Dyke.

The means of a clear and rational comprehension of the significance
of the blood groups were first supplied by the work of Hirschfeld and
Hirschfeld (1919) [16]. These authors, working at Salonica during the
war when individuals of many races were gathered there and available for

When blood groups
of parents are
I and I
land II
I and III
I and IV
Hand II
II and III
II and IV

III and III

IV and IV

Dyke and Budge: Human Bed Cells

investigation, found that while in races from North and Western Europe
the A property was the commoner, individuals bearing the B property became
proportionally more frequent as races from the lands to the south and east of
Central Europe were investigated. Thus while Group II formed 43*4 per cent,
of the English population and 43 per cent, of the Germans, and Group III
only 7*2 per cent, and 12 per cent, respectively, the matter was reversed
among natives of India who showed 41*2 per cent, of Group III individuals
and only 19 per cent, of Group II. Up to the present this work remains
almost all that has been done along these lines. Approaching the matter from
a somewhat different angle, however, Verzdr and Wezeczky (1921) [17] have
investigated the relative proportions of the blood groups in three different
types of population all found in Hungary, but racially very different. The first
type consisted of the inhabitants of some villages near Buda-Pesth, colonized
two centuries ago from Germany ; the second of the inhabitants of a Hungarian
town, and the last, of the Gypsies who wander through Hungary but do not
marry outside themselves. The first population gave a distribution of the
four groups, similar to that found by von Dungern and Hirschfeld in Germany;
the second showed a distribution of the groups differing from this and
approximating to that found among the Turks, while the Gypsies showed a
distribution of the groups differing from both of these but approaching that
found among the inhabitants of India.

The explanation of these facts offered by L. Hirschfeld and H. Hirschfeld
is that the properties A and B respectively are typical of two different sorts of
blood, each characteristic of a special type of the human race. They suggest
that these two types of the human race may have had separate origins, the
one in North-western Europe and the other in Central Asia. Originally
the race arising in North-western Europe would have consisted entirely of
pure homozygous Group II individuals having the formula Ab Ab, while the
Central Asian race would have consisted of Group III individuals, having
the formula Ba Ba. By their commingling, these two pure races would give
rise to all the four blood groups as we now know them.

Possibility of a Lethal Factor.

Here arises a point of some interest. It is obvious that the offspring of
the first filial generation resulting from the union of two individuals of the
formula Ab Ab and Ba Ba y must all have the constitution Ab Ba —that is to
say, they will all belong to Group I. The gametes producedjby these offspring
will have the four possible formulae AB , Ab , Ba , and ab. The results of the
interbreeding of the offspring of the first filial generation is shown in the chess
board below :—

1 Ba

| ab

1 _

alt

a h

A B

Section of Pathology

This is an application of Mendel’s 9, 3, 3, 1 Law and from it it would
appear that in the union of two homozygous individuals of Group II and III,
no offspring of Group IV can appear in the first generation, while in the
second they can only appear in the proportion of 1 in 16 of the total offspring
and 1 to 9 of those of Group I. These considerations would lead us to expect
that in a mixed population individuals belonging to Group I would be as
common as, if not commoner than, those of Groups II and III. Group IV,
consisting of double recessives, mating between whom can only produce other
individuals of the same group, is in a different category and will always tend
to increase in numbers in a mixed population. Actually such data as are to
hand show that in all races, no matter what are the relative proportions of Groups
II and III, Group I is always the least numerous. It would seem that some
factor exists inhibiting the ready production of Group I individuals while no
such inhibition exists in the case of other groups.

Some suggestion as to the possible nature of this inhibiting factor is supplied
by the known facts in regard to the lethal effect exerted in certain instances by
the doubling of the dominant. The classical example of this is the case of the
dominant yellow in tame mice. Cu6not [18] first pointed out that the union of
gametes each bearing this particular dominant resulted in a non-viable zygote,
and ample evidence in support of his thesis has been advanced by American
workers. Morgan and his co-workers (1919) [19] have found a number of
instances of a similar lethal effect of the doubling of a dominant in the case
of the fly Drosophila.

It seems possible that something analogous may occur in regard to the
dominants A and B in the human being. Simple doubling of the dominant A
or B in the zygote can hardly constitute a lethal factor, as, if it did so, homo¬
zygous individuals of Group II or III, with the formula Ab Ab and Ba Ba
respectively could not exist. Zygotes containing but one of the dominants as
in heterozygous Group II {Ab ab) or III {Ba ab), or containing neither, as in
Group IV {ab ab ), are also perfectly capable of full development. That is to say
of the known formulas we have some containing neither dominant A nor B
(Group IV), some containing only one (heterozygous Groups II and III) and
some containing one dominant doubled (homozygous Groups II and III).

In all these cases it is to be observed, in the first instance, that a dominant
never occurs without its reciprocal recessive and secondly that, for all these
formulae, it is possible for segregation of the factors to take place in such a
way as to result in two gametes, neither bearing more than one dominant.

Of the four possible formulae for Group I the two above propositions hold
for one only. The four theoretically possible formulae are AB AB , AB Ab, AB
aB and AB ab. In the first formula no recessives are present at all, in the
second and third two dominants are present unaccompanied by their reciprocal
recessives. In the first formula segregation of the factors must result in
gametes each containing two dominants; in the second and third {AB aB and
AB Ab), one gamete must contain two dominants. The fourth formula {AB ab)
fulfils both propositions and resembles the known existent formulae for the
other groups; each dominant is accompanied by its reciprocal recessives and
segregation of the factors can occur in such a way as to produce gametes each
bearing only one dominant {Ab and Ba).

Two possibilities exist: (l) That in Group I only individuals of this last
formula, AB ab, exist ; and (2) that the three other formulae may exist in
individuals, but that the gametes produced by them bearing two dominants are
not capable of fruitful union.

Dyke and Budge: Human Bed Cells

On fchis second assumption an individual of the formula AB AB, would be
completely sterile, while individuals of the formulas AB aB and AB Ab would
produce only half their proper number of fruitful gametes.

Either assumption would account for a relative diminution of Group I
as compared to Group IY individuals. Which is correct can only be ascer¬
tained by a series of observations of unions involving Group I individuals and
such a series, owing to the rarity of Group I, must necessarily be difficult of
collection.

REFERENCES.

[1] Von Dungern, E., and Hirschfeld, L., “ Ueber Vererbung grnppenspezifischen Struk-
tnren des Blutes,” Zeitachr. f. Immunitatsforschung. Orig. 6, 1910, p. 284. [2] Landsteiner, K.,
“ Ueber Agglutinationerscheinungen normalen menschlichen Blutes,” Wien klin. Wochcnschr
1901, xiv, p. 1133. [3] Von Dkcastello, A., and Sturli, A., “Ueber die Isoagglutinine im

Serum gesunden und kranken Menschen,” Munch. Tried. Wochenschr., 1902, xlix, p. 1090.
[4] Jansky, Jan, “ Hfematologische Studien bei Psychotikern,” Klin. Sbomik., No. 2, 1907;
reviewed in Jahresb. Uber Neur. und Psych., 1907, xi, p. 1092. [5] Moss, W. L. “Studies on

Isoagglutinins and Isohfflmolysins,” Bull. Johns Hopkins Hosp., 1910, xxi, p. 63. [6] Hektoen,

L., “Isoagglutination of Human Corpuscles,” Journ. Infect. Dis ., 1907, iv, p. 297. [7] Koeckert,
H. L., “A Study of the Mechanism of Human Isoagglutination," Journ. Immunol ., 1920, v. f
p. 629. [8] SchOtze, H., “ Haemagglutination and its Medico-legal Bearing with Observations on

the Theory of Isoagglutinins,” Brit. Journ. Exper. Path., 1921, ii, p. 26. [9] Dyke, S. C.,

“On Isohremagglutination,” Brit. Journ. Exjrer. Path., 1922, iii, p. 146. [10] Dyke, S. C.,

“ On Blood Grouping and its Clinical Applications, with a Simple Method of Group Determina¬
tion,” Lancet , March 26, 1922. [11] Learmonth, J. R., “Inheritance of Specific Isoagglntinins

in Human Blood,” Journ. Genetics, 1920, x, p. 147. [12] Ottenburg, R., “Hereditary Blood

Qualities, Medico-legal Application of Human Blood Grouping,” Journ. Immunol., 1921, vi, p. 303.
[13] Ottenburg, R., “ Medico-legal Application of Human Blood Grouping,” Journ. Amer. Med.
Assoc., 1922, lxxviii, p. 873. [14] Happ, W. M., “Appearance of Isoagglutinins in Infants and

Children,” Journ. Exper. Med., 1920, xxxi, p. 313. [16] Dyke, S. C., “On the Medico-legal

Importance of the Blood Groups,” Lancet , 1922, ii, p. 1271. [16] Hirschfeld, L., and

Hirschfeld, H., “ Serological Differences between the Blood of Different Races,” Lancet, 1919,
ii, p. 675. [17] Verzar, F., and Wezeczky, O., “ Rassienbiologischen Untersuchungen mittels

Isonamagglutinin,” Biochem. Zeitschr., 1921, cxxvi, p. 33. [18] Cuenot, cited by Morgan, vide

infra. [19] Morgan, T. H., “ The Physical Basis of Heredity,” Philad. and Lond., 1919.

PROCEEDINGS

OP THE

ROYAL SOCIETY OF MEDICINE

EDITED BY

Sib JOHN Y. W. MacALISTER

UNDER THE DIRECTION OK

THE EDITORIAL COMMITTEE

VOLUME THE SIXTEENTH

SESSION 1922-23

SECTION OF PSYCHIATRY

LONDON

LONGMANS. GREEN & CO., PATERNOSTER ROW

1923

Section of fl>0\Kbiatr]?.

OFFICERS FOR THE SESSION 19*2*2-23.

Cresident —

C. Hubert Bond, C.111]., M.D.

Vice-['resident h —

Henry Head, M.D., F.R.S.

Hon. Secretaries —

G. F. BahhaM, M.D.
Edward Marothek, M.D.

Other Members of Council —

E. Farquhar Buzzard, M.D.
IIarrv Campbell, M.D.
Henry Devine, O.B.E., M.D.
Bernard Hart, M.D.

Percy T. Hughes, M.B.

H. Crichton Miller, M.D.
Hubert J. Norman, M.B.
Bedford Pierce, M.D.

W. A. Potts, M.D.

C. Stanford Bead, M.D.

T. Grainger Stewart, M.D.
Maurice B. Wright, M.D.

livpresenlatice on Library Committee —
K. H. Cole, M.D.

liepresentatire mi Kditoriul Committee

Edward Maeother, M.D.

SECTION OF PSYCHIATRY.

CONTENTS.

November 14, 1922.

F. L. Golla, M.B.

The Organic Basis of the Hysterical Syndrome

I’AUK

December 12, 1922.

Mary C. Bkll, M.B.

The Use and Abuse of the Relationship between Doctor and Patient in
the Practice of Psychotherapy ... .

January 9, 1923-

Lkitch Wilson, M.B., D.P.M.

The Endocrine Factor in Mental Disease

March 13* *923.

Huhkrt J. Norman, M.B.

Genius and Insanity

February 13, 1923

& A. Klnnikk Wilson, M.D.

Pathological Laughing and Crying ...

3‘J

The Society does not hold itself in any way responsible for the statements made or
die views put forward in the various papers.

London :

John Bale, Sons and Danielsson, Ltd.,
Oxford House,

Great Titchfield Street, Oxford Street, W. 1.

Section of p0\>cbiatr$.

President—Dr. C. Hubert Bond, C.B.E.

The Organic Basis of the Hysterical Syndrome.

By F. L. Golla, M.B.

A SEARCH for the organic disturbance that underlies the hysterical syn¬
drome may appear to be a very unpromising quest. It is generally accepted
that hysteria is a purely mental disorder, that its origin is psychogenic and
that it can only be fruitfully studied by inquiry into the subjective states
of the patient. Now, as physicians, we are concerned only with purely
scientific methods of investigation, and to the man of science such a term
as “ disorders of mind ” can have no scientific meaning. All that is given
us, in the study of the symptomatology of hysteria, is a disorder of conduct;
of mind and the possibility of disorders of mind we have no objective
knowledge.

The study of conduct is a purely objective study of all those activities
which collectively represent all that we can know by observation of the
exterior aspect of life. It requires a trained and experienced observer for ever
on his guard against any tendency to introjection, that is, to interpretation of
what is objectively given, in terms of his own subjective states. Laboratory
methods are out of place in such an investigation. When, however, we
attempt to discover the disorders of the bodily mechanisms by which conduct
is expressed, we have to deal with a physiological problem which should be
investigated by the methods of experimental physiology. That a disorder of
the mechanism of conduct must precede the evolution of the hysterical syn¬
drome appears to be a certainty. By some strange confusion of thought those
observers who profess to find by analytical methods an initial psychic trauma
at the origin of all neuroses tend to deny this pre-existence of a disordered
nervous mechanism, though really it is a necessary inference from their own
observations.

One fact emerges from all the investigations that have been conducted in
recent years by the methods of analytical psychology, namely, that in the
vast majority of cases the experience of the neurotic differs in no way from
those that fall to the lot of the ordinary healthy man. The data furnished by
the war are often cited as an argument to the contrary, but these really furnish
irrefutable evidence that an organic disturbance or failure of organic equilibrium
preceded the manifestations of the neurotic symptoms and could not have been
caused, however much it may have been aggravated, by the individual experi¬
ences. In the armies of the allies and those of the enemy millions of men
were exposed to similar conditions, yet only a small number were brought to

F-Ps 1 [A November 14, 1922.

2 Golla: The Organic Basis of the Hysterical Syndrome

the hospitals suffering from a neurosis. Doubtless all who were in the line
showed for a longer or shorter period the disturbances due. to fatigue or
functional hypertrophy of certain nervous mechanisms, but only those suc¬
cumbed who were organically unsound. Sir Frederick Mott was able to
obtain a history of pre-existing neurotic symptoms in 80 per cent, of the cases
of soldiers under his care for neurotic disorders. Were the patients in these
cases of organic nervous weakness the victims of experiences in infancy and
childhood which had left an indelible mark on their nervous constitution ?
There is no reason to suppose that as a whole their experiences differed from
those of the average child in their particular social milieu. We are justified in
assuming an organic disability as an antecedent to every neurosis, and in
employing methods for the objective evaluation of organic efficiency in looking
for it. Even granting such an underlying bodily disorder, it might appear by
no means likely that it could be demonstrated by the methods at our disposal,
were it not that the application of pathological and physiological methods in
the study of a similar problem in psychiatry has within the past few years
yielded such brilliant results. A short time ago the pathology of dementia
praecox stood in much the same position as that occupied by the neuroses to¬
day. It is due to the epoch-making researches of Sir Frederick Mott and his
pupils that dementia praecox is now recognized as a degenerative condition
profoundly affecting practicallv every bodily function. The study of morbid
anatomy has revealed the existence of wide-spread degenerative cell changes,
and the chemical researches of Pighini in Italy, and of Sidney Mann in Sir
Frederick Mott’s laboratory, have shown that profound metabolic disturb¬
ances are the functional expressions of many of the anatomical changes.
In the light of these findings it should be impossible for anyone to main¬
tain the possibility of a psychogenetic origin of dementia praecox. Since
dementia praecox is merely a unit in the constellation of hereditary psychoses,
any of which may equally well befall the other members of a psychopathic
family, there is little room to doubt that a similar organic basis will be
discovered for all the psychoses.

Now hysteria, for obvious reasons, does not permit of investigation by the
methods of morbid histology, and consequently we are dependent on physio¬
logical methods. The clue to what particular system of the bodily mechanism
is most likely to be affected must be sought in a survey of the clinical aspect
of hysteria. The mass of contradictory views on hysteria lends colour to
Lasegue’s dictum : “ The definition of hysteria has never been given, and
probably never will be.” Much of the chaotic condition of thought on this
subject arises from an attempt to study the psychology of the neuroses from a
subjective rather than from a purely objective point of view. The objective
method, it is true, cannot furnish more than an objective account of the
problem, teleological significance cannot be expressed, nor can desire or
conation bo properly discussed: but at least it has the merit of making it
possible to represent hysteria as a clinical entity in terms of behaviour.
Bernheim was the first to adopt an objective standard in discussing the
hysterical syndrome, and he pointed out that all the symptoms of hysteria
were such as might be produced by hypnotic suggestion. Babinski has
amplified this view by demonstrating not only that hysterical symptoms are
such as might be caused by suggestion but that they can actually be removed
by counter-suggestion. To quote Babinski’s own words: “Hysteria is a
pathological state, manifested by disorders which it is possible to reproduce
exactly by suggestion in certain subjects, and can be made to disappear by the

Section of Psychiatry

influence of persuasion (counter-suggestion) alone.” This definition of
Babinski’s has been received with almost universal assent. Its acceptance
allows us to determine the clinical entity to which this label can be affixed
without committing us to any theory of the psychology of hysteria. It
implies however that hysteria can only manifest itself through mechanisms
that are normally under voluntary control. Limited by the subjectivism that
defines hysteria as only differing from fraud in its moral aspect, the school
of Babinski declines to consider as hysterical any symptom that cannot be
produced by an effort of will. This is a return to the subjective method,
par excellence .

Of will and its limitations we have no objective knowledge, and, as Spinoza
said: “ No one has yet learned from experience what the body, regarded
merely as a body, is able to do in accordance with its natural laws, or what it
cannot do. For no one knows enough about the constitution of the body to
examine all its functions.” This attempt by Babinski and his followers to
eliminate from the syndrome of hysteria all symptoms that are not directly
under control of the will, has led to many errors, the most glaring of which is
the relegation of late hysterical contracture to the position of a reflex con¬
tracture set up by irritation of the wound, on the ground that it is not directly
curable by counter-suggestion, and that the contracted muscle shows certain
abnormalities of response to electrical stimulation, and is not being completely
relaxed under anaesthesia. It is now generally admitted that the persistence
of the contracture when volition has been abolished by anaesthesia is due to
degenerative change in the muscle, whose normal metabolism and lymph-
supply has been interfered with by the persistent hysterical contraction. Such
errors are bound to creep in when an attempt is made to delimit the power
of the brain to effect bodily changes—thus, when an unpleasant thought is
voluntarily recalled, it may be accompanied by some such emotional con¬
comitant as blushing, and a voluntary act is here manifested by an involuntary
mechanism. Such difficulties need not affect the truth of Babinski’s definition,
though they impose a certain elasticity on its application. An evaluation of
the psychology of the hysterical individual presents considerable difficulties.
The problem is to discover whether the clinical entity is an expression of a
pathological nervous state, and it is only too easy to confuse the symptoms
that the patient exhibits because he has hysteria with those that might
indicate a nervous diathesis. Most psychological investigations of hysterics
fail because of this difficulty. It is not from the specialist who sees the patient
in the full possession of his malady, but from the general practitioner or an
intelligent schoolmaster who has known him for most of his life, that w*e may
expect the most valuable evidence. The picture obtained from these sources
is that of an eccentric individual without strong or durable emotions, though
anxious to impress the outer world with the gravity and intensity of his
experiences. Always more ready than a well-bred person should be to
impress his fellows, he would not willingly apply himself to any task in¬
volving strenuous exertion, fatigue, or danger. The total personality
conveys an impression of flimsiness. He appears to be a very different
person from the volcano of ill-suppressed sexual passions that some writers on
psychotherapy have portrayed.

There is one other cardinal symptom of the hysteric that has been
emphasized by all observers, and that is his abnormal suggestibility. So
far, then, all the data obtained from a purely objective survey of hysterical
conduct point to an egocentric weakling, deficient in that stability of the

4 Golla: The Organic Basis of the Hysterical Syndrome

nervous system which resists outside suggestion. The data are meagre,
but such as they are they apparently point to some disturbance of emotional
activity.

In the nervous system there are two systems of afferent function. One
system reacts to stimuli of a nocuous nature; the effector organs which
manifest its activity are either organs not under the power of conscious effort
or else certain combinations of reflexes which cannot be voluntarily activated.
The great terminal ganglions for this system are thought to lie in the thalamus.
This system is phylogenetically older than the cortical system. It originates
the defensive reflexes by which the body reacts as a whole to nocuous stimuli,
whether by glandular, visceral, vascular, or muscular pattern reflexes. The other
system of nervous mechanism is that by which appropriately adjusted reflex
patterns are combined in response to stimuli not in themselves possessing
either nocuous or benign characteristics. The terminal co-ordinating centre of
this system is the cortex. Its function is discriminatory and this discriminatory
adjustment of certain reflex mechanisms to various stimuli is correlated with
consciousness.

The two systems are not, however, independent. When the activity of the
cortical processes is impeded by opposition arising from either external or
internal stimuli these obstructing stimuli constitute what is in effect a nocuous
stimulus, inasmuch as they threaten the persistence of the normal activities of
the organism. In reply to such a nocuous stimulus the resources of the body
as a whole are mobilized to overcome the resistance, or in other words an
activation of the thalamic system occurs. Conversely, changes of the activity
of the thalamic aflfector organs, when they reach a certain degree of intensity,
stimulate the cortical receptors and we become aware of a change in the
common sensation of the body. The consciousness of such a disturbance
constitutes what we term an affective state, or, as some prefer to call it,
an emotional state.

It would be impossible within the limits of this paper to deal with even
a condensed exposition of the methods by which the organic resonance of
affection is determined. I can only indicate the various mechanisms in which
responses can be instrumentally recorded, and at the same time I must remind
you that the most obvious and at the same time the most instructive of all the
signs of emotion—namely, the facial expression—eludes by its very nature
all attempts at instrumental control, whilst attempts to record inflection of
the voice, which constitutes in itself the language of emotion, are as yet
unsuccessful.

In the first place I would draw your attention to the muscular response to
a nocuous stimulus as manifested by an increase of tonus and, as I originally
pointed out in the Croonian lectures, this increase of tonus is not in the nature
of a voluntary tetanic contraction, as it shows none of the characteristics of
the electromyogram of a voluntary contraction. The increase of tonus affects
those muscles that are relaxed rather than those already in some state of
postural contraction and its influence may be well demonstrated in the knee-
jerk. If the knee-jerk be recorded with some of the precautions to which
I have drawn attention elsewhere, it is possible by its fluctuations to follow,
only roughly of course, some of the fluctuations of affective state in the patient.
We next have the respiratory response to a nocuous stimulus. As you will
observe there is no obvious point of distinction between the two records of
grief and anger. Here again great care must be taken to avoid the records
being complicated by unnatural breathing, which invariably occurs when the

Section of Psychiatry

attention of the patient has been directed to it. I find that the best results
are obtained from unintelligent patients who can be persuaded that the
apparatus placed on the thorax is for the purpose of recording the heart beat.
The correlation shown in the slide, between the muscular tonus of the
quadriceps and the flattening of the respiratory curve indicates the probability
that an increased tonus of the respiratory muscles may play some part in the
altered respiratory movement. Next we observe the alteration of the pulse
rhythm in response to a nocuous stimulus, an alteration which, as I have
pointed out elsewhere, is more probably due to stimulation of the accelerator
than to inhibition of the vagus. The next slide shows the plethysmographic
response of the arm to a nocuous stimulus causing a reflex vasoconstriction.
The affective rise of blood pressure is also shown. . The extraordinary
sensitiveness of the pressure of the cerebro-spinal fluid and the relation of such
changes of pressure to respiratory oscillations of emotional type are shown in
the accompanying slide. Now all these reactions, and one or two more which
concern the internal pressure of the hollow viscera, have this in common:
though they are not under control of the will they can yet be materially
altered by the voluntary innervation of neighbouring structures. Thus the
respiration can be controlled by forced breathing, the muscular tonus altered
by voluntary contraction, the blood-pressure by fixation of the thoracic
muscles, &c. There is, however, one type of affective reaction that cannot
be affected by voluntary effort: this is the diminution of skin resistance that
takes place in response to a nocuous stimulus, commonly termed the psycho¬
galvanic reaction. Physiologically there seems to be little doubt that this
increase of conductivity or reciprocal diminution of skin resistance is the
expression of an increase in tissue activity occurring in the sweat-glands of
the skin in response to a nocuous stimulus. I have elsewhere dealt with the
inevitable character of this easily measured reaction. It i$ not under the direct
control of the will, it can only be elicited by stimuli that have a truly nocuous
character, whether such stimuli be physical or psychical. Thus a prick, the
threat of a prick, the pangs of hunger, or the prospect of losing a fortune on
the Stock Exchange, will be in their several measures efficient stimuli.

The threat to cause bodily discomfort is the simplest form of verbal
stimulus. From this point onwards the stimuli may be-elaborated by the
representation of circumstances, either past or present, that are opposed to the
well-being of the subject or are in conflict with the general tendency of his
conduct—that is stimuli such as will on the affected side evoke the feelings of
grief or anger. So much for the galvanic response to external stimuli, but
even more important is the galvanic response to stimuli whose immediate
origin is in the autogenous neural processes of the subject. The spontaneous
representation of some disagreeable or painful circumstance will serve equally
well to elicit the galvanic reflex. Whether the subject silently recalls some
past experience of a painful nature, or whether he communicates it verbally to
the observer,the representation will in both cases evoke a diminution of skin
resistance. The simulation of emotional states invariably fails to give the
galvanic reflex ; it is possible to recite emotional poetry and to abuse an
imaginary opponent with the greatest energy without causing any movement
of the galvanometer spot. It is indeed instructive to sit quietly by oneself
and observe what thoughts and reminiscences have an affective tone and
in how many instances subjects on which we think we ought to feel strongly,
fail to display an organic emotional reaction.

I have found that the galvanic response exhibits the same latent period as

6 Golla: The Organic Basis of the Hysterical Syndrome

the other form of response of the affective mechanism—the convenience with
which it can be calibrated and studied, and the impossibility of voluntarily
controlling it, make it the most suitable response of the affective mechanism
for experimental investigation though it is by no means the most delicate.
A study of the time relations of the response illustrates the dissociation of the
affective response from the discriminatory or cortical response to a stimulus.

1 show on the screen the photographic record of an experiment which makes
this clear and incidentally throws a new light on a question over which
psychologists still quarrel owing to their devotion to introspective methods—
namely, the validity of the James-Lange theory. This is the record of the
reaction of a subject to a nocuous stimulus manifested by the galvanic reflex—
a voluntary motor reaction and a start. The subject was instructed to press
a key actuating a signal when he heard a pistol shot. The record shows that
the first event—an involuntary motor reaction or start—took place about '008
second after the shot. This is, as Sherrington showed, a mesencephalic reflex
and need not, for the moment, detain us; though, as we shall see later, it is
not without bearing on certain hysterical manifestations. The next event was
the voluntary depression of the key by the subject as soon as he perceived the
shot, the latent period of the voluntary discriminatory response was a normal
one of 0*2 second. The third event is the movement of the galvanometer
fibre at the beginning of the galvanic reflex. The latent period of this reflex is

2 seconds. If the galvanic reflex be taken to indicate one of the many bodily
responses that make up the general state of bodily activity the sensory
equivalent of which is an affective state, then this affective or emotional state
is arrived at quite 1*8 seconds after the initial stimulus has been perceived and
acted upon. Now this observation is typical of all records of affective or
emotional response—the discriminatory or intellectual mechanism acts in the
first instance alone; later the general bodily reaction to the nocuous stimulus
occurs and the affective state is perceived. Now in the hysterical subject we
have to a greater or less extent an enfeeblement, or even a virtual suppression
of the affective response.

In 1918 I had the opportunity of examining all the cases of neurosis that
passed through the Maudsley Clearing Hospital, which, at that time, had over
six hundred beds. I found that the large class of patients exhibiting those
motor and physical symptoms which constitute the hysterical syndrome could
be readily differentiated from those exhibiting other types of neurosis, by the
extraordinary depression of the galvanic response to any form of stimulus.
Such patients would start or tremble at a loud noise or painful stimulus when
a normal man would hardly budge, but their galvanic response would be either
absent or less than normal. Though they might talk of great emotional
perturbation there was no corresponding galvanic reflex. The mise en scdne of
the galvanometer room seemed to be extremely conducive to the exhibition of
hysterical crises, and I had the opportunity of observing the galvanic reflex
during many such scenes. One young soldier suffering from a hysterical
contracture broke down during an examination; tears rolled down his cheeks,
he addressed his dead brother in language savouring of a South London melo¬
drama. He asked why he himself had not been killed in his brother’s place,
so that the favourite son might have been left to comfort the poor old father,
and all the time, while he wailed and wept, the spot of light from the galvano¬
meter mirror remained steady.

Now the counterfeiting of rage or grief, no matter how dramatically per¬
formed, is unaccompanied by the electric signs of activity of the affective

Section of Psychiatry

mechanism. In these observations we have then, I think, the key to hysterical
behaviour. It is purely imitative. This was my view in 1918 and I have
since found nothing to cause me to modify it. Not only is the response to the
alleged emotional states absent in the hysterical crisis, but the hysteric reacts
as a rule subnormally to all forms of adequate—that is nocuous—stimuli. A
study of the time relations of the affective and the discriminatory response
has shown that the nocuous stimulus is recognized and elicits an appropriate
cerebral response an appreciable time before the bodily mechanism of affection
reacts. We have in fact a kind of dualism : on the one hand the discriminatory
mechanism associated with intelligent behaviour, and on the other, the reaction
of the organism as a whole to a nocuous stimulus. Herein lies the explanation
of hysterical conduct. The hysteric is as capable as the normal man of
recognizing that the situation in which he may find himself is one of potential
peril or discomfort, he can respond immediately to the situation by an appro¬
priate cortical reaction, but if the stimulus be continued, his activity lacks the
reinforcement supplied by bodily reaction. To determine his line of conduct
a representation of the situation is necessary and such a representation must
normally involve the activity of the mechanism of affection since in no other
way can the unpleasantness of the situation—the affective state that reinforces
the intellectual appreciation of its danger—be recognized. Deprived of this
determining force his reaction to the situation will be at the mercy of any
casual stimulus. Since the affective reaction fails him, he has recourse to
other forms of expression more or less distantly connected with the feeling of
unpleasantness. The association of bodily ailments with the feeling of distress
will most readily furnish the subject matter of the drama by which the patient
endeavours to represent to himself and to symbolize to the external world
the fact that his activities are threatened or impeded by some nocuous influence
in the environment. Hence the hysterical symptoms really constitute a
method of self-expression, primarily for egoistic and secondarily for social
needs, which has been conditioned by an organic disability of the mechanism
of affection.

There is another cardinal hysterical symptom that is referable to the same
organic disability—namely, the abnormal suggestibility of the hysteric.
Suggestibility has been defined by McDougall as a process of communication
resulting in the acceptance with conviction of the communicated proposition
in the absence of logically adequate ground for its acceptance. Our strongest
bond with logical reality is that furnished by the feelings or emotions, for these
constitute our strongest defence against the irrational. Mind, disassociated
from feeling, is mind very much at the mercy of any suggestion. The bodily
reaction against a suggestion that is in discord with the general tendencies of
our activity is the real guarantee against its acceptance. It is just this
defence that the hysteric lacks; to a greater or less extent his activities can
be unduly influenced both by autogenous and heterogeneous suggestions. In
other words, the innate and habitual pattern reflexes, having lost the mechanism
of bodily reaction by which they reply to stimuli tending to interfere with
their activities, are no longer a potent protective system as they are for the
normal man and can be displaced or disassociated by any new stimulus of
sufficient potency.

Another, but less important, phase of the hysterical syndrome that has
impressed most observers is the excessive motor reflex response of the hysteric.
One of the most characteristic bodily responses to mental or physical effort is
a marked increase of muscular tonus—-every muscle is tightened and the

8 Grolla: The Organic Basis of the Hysterical Syndrome

respiratory movements are reduced to a minimum. Owing to his disassociation
from states of feeling the hysteric appears to assume readily that state of
muscular hypertonicity which accompanies effort, and, as I have shown else¬
where, there is an intimate connexion between this hypertonic state and the
increase of the deep reflexes. In hysteria the knee-jerk may not only be
increased but may be followed by a series of irregular clonic contractions
which, however, as shown in the accompanying slide, may be readily differen¬
tiated from the true quadriceps clonus of a lesion of the pyramidal tract when
recorded by the oscillograph or the string galvanometer. The response to an
auditory stimulus frequently takes the form of an exaggeration of the normal
“ start ” which is, as we have seen, a mesencephalic reflex.

Is the diminution of the affective response in the hysteric of central or
peripheral origin ? We have not at present the data to decide this question
but the two slides that I show on the screen are at least suggestive. The
resistance of the skin was shown by Waller to undergo a diurnal variation
following closely the diurnal variation of temperature. I took advantage of
this observation to determine the relation of the galvanic responses evoked by
uniform stimuli to the initial skin resistance. Maximal stimuli were used,
and for this purpose a pistol shot was found most convenient. The chart
represents the mean of observation conducted on three successive days, but
the difficulties in obtaining the subject at any one time under approximately
the same condition are very great. The observations clearly indicate that the
maximum affective response occurs round about mid-day when the resistance
of the skin is at its lowest, and there is a rough correspondence between the
resistance of the skin and the reflex throughout the day. There is good
reason to suppose that the galvanic reflex at any rate—and most probably all
forms of affective or emotional response— are effected by the vegetative nervous
system. Now one portion of the vegetative system is constituted by the
sympathetic, and the excitability of the sympathetic system may be readily
increased by the administration of thyroid extract. By giving large doses of
thyroid in the early morning I was able both to diminish the mean value of
the skin resistance and to mask its diurnal variation. At the same time the
galvanic response to uniform sound stimuli was considerably increased as
3 hown by the second slide. Now the diminished affective response of the
hysteric is accompanied by an increased skin resistance, and in four cases I
have succeeded in producing a normal type of response together with a
decrease of skin resistance, by the exhibition of thyroid. In view of the
suggestibility of the hysteric I should hesitate to attach any value to his
statements of an improvement in their general condition. Thyroxin sensitizes
the nerve endings of the sympathetic and the organic insufficiency of the
affective system must be central. It is not, however, impossible that a drug
acting on the peripheral mechanism might tend to mask a deficient activity on
the part of the centre. Goetsch has devised an intradermic test that serves to
demonstrate the existence of hyperexcitability of the sympathetic system. The
reaction depends on the demonstration of sympathetic hyperexcitability by
injection of minute quantities of adrenalin into the superficial layers of the
epidermis. Using this test, as modified by Ascoli and Faggioli, I have
generally found that the excitability of the subepidermal test lies between
dilutions of 1 in 200,000 and 1 in 1,000,000 of Parke Davis adrenalin solutions
in normal cases, that in hysterical cases the excitability lies between dilutions
of 1 in 200,000 and 1 in 500,000, whilst in some cases of disturbance of the
menopause, of arterial hypertension, of Graves’ disease, and sometimes in

Section of Psychiatry

pregnancy, the excitability is increased, giving further positive results
with dilutions up to 1 in 20,000,000. I attach no importance to this test
except that it affords evidence that the excitability of the sympathetic system is
never increased in hysteria and, if anything, tends to lie on the hypo-excitable
side.

In regard to this point other experiments are in progress, and I hope by
means of an exquisitely delicate test for blood-sugar devised by Dr. Calvert
that Captain Mann and myself may gain some additional information as to the
lability of the vegetative nervous system to central and peripheral stimuli in
the normal hysterical subject. Experiments are also in progress at the
Maudsley Hospital which may tend to show whether the apparent sluggish¬
ness of the mechanism of emotional response is associated in hysteria, as it is
in dementia praecox, with a disturbance of oxidation processes. The age at
which hysteria is most common suggests that its manifestations are in the
main coincident with the period when the stress of the external world bears
most heavily on the nervous organization which has not yet established
habitual reactions. The following table is that of Kraepelin :—

Percentage Age-incidence of Commencement of Symptoms.

10th year 15th year 20th year 25th year 35th year 40th year 45th year 50th year

0*9 21 368 12*1 63 44 1*9 21

per cent, per cent, per cent, per oent. per cent, per cent, per cent, per cent.

Although Kraepelin’s statistics distinctly show that the incidence of hysteria
in his 430 cases is most marked during the period of adolescent stress, I find it
hard to believe that such a sharp descent in the percentage of incidence between
the twentieth year and the twenty-fifth year is only explicable by the forma¬
tion at that age of suitable responses to the exigencies of adult life. It suggests
the definite amelioration of the organic response rather than that a disappear¬
ance of environmental stress is the responsible factor. One thing at any rate
seems to be clear, and that is that the hysterical syndrome tends to fade away
with increasing age, and it seems more than a coincidence that, contrary to
what one would expect, the affective response tends to increase in magnitude
with increasing years. The late Dr. Waller first called my attention to this
interesting fact, which I can unreservedly confirm.

In presenting the foregoing objective view of the hysterical syndrome I
have endeavoured to confine myself entirely to the problem of the organic
basis of hysteria. In the elucidation of this problem reference to the investi¬
gations of workers who adopt the methods of psycho-analysis would be out of
place. Whatever may be the value of this method, it can no more give us
information about the organic basis of a neurosis than it could about the
state of the meninges in general paralysis. There is no necessary antagonism
between the methods of introspection and those of pure behaviourism. Should
the views that I have here propounded in a tentative fashion prove to have a
solid foundation in pathology, any investigation from the standpoint of analytic
psychology must ultimately amplify our conceptions of the underlying disorders
of the nervous mechanism.

DISCUSSION.

Dr. Stanford Read said that Dr. Golla had pointed out, as many other opponents
of a more or less purely psychogenetic viewpoint with regard to the psychoneuroses
had done, that the normal individual tended to have the same early environmental

10 Golla: The Organic Basis of the Hysterical Syndrome

experiences as the neurotic, and that, therefore, psychic traumata in childhood could
hardly have any setiological significance. The psychogenic school, however, only
pointed to a likely exaggeration or persistence of such traumata and dwelt rather on
the fact that it was the abnormal attitude towards such factors that had the deleterious
effect and so brought about later pathological results. The fact that organic changes
could be set up by emotional causes had been amply established by war neurological
experience, and Sir Frederick Mott’s researches in dementia praecox by no means
proved an organic basis for that condition, though, as the organism was an integrated
whole, this factor could not be neglected. McDougall had lately attacked Mott on this
question. Babinski’s ideas were probably less widely accepted now in England than
formerly, and the results of therapeusis on his lines had wrought much havoc among
war pensioners, through neglect of the mental state underlying the symptoms.
Neither Babinski nor Dr. Golla had explained in any way why the hysteric was so
hyper-suggestible. Too much stress could not be laid on the point lately insisted on by
Sherrington, that it was stepping from one world to another—and to an incommen¬
surable one—to pass from a nerve impulse to psychical processes, and that it was quite
impossible to deal with mental actions in terms of nervous action or vice versa.
Dr. Golla’s experiments were of interest, but in no way did they throw any light on the
sources of the hysterical syndrome. Keinpf’s work was of importance as an attempt to
correlate physiological changes with mental processes and states.

Dr. MILLAIS Culpin said that he found some difficulty in placing the “ hysterical
syndrome ” among the varied cases that were met in the psycho-neuroses, and asked the
lecturer for a more precise clinical definition of the type of case in which the reactions
he described were to be found. Speaking as a clinician he asked whether pure science
was as helpless in regard to the hysterical syndrome as it was in regard to dementia
praecox.

Sir Frederick Mott said that he thought there was some misapprehension with
regard to Dr. Golla’s position in respect to psychological influences upon the bodily
condition. Dr. Golla did not deny this, but he emphasized the importance of studying
objective signs by every means at our disposal. He (Sir Frederick Mott) supposed that
Dr. Golla assumed that in the subject of hysteria there was a genetic bodily
inadequacy by which the patient, under the influence of psychological stress, was unable
to make normal mental adjustments. Dr. Golla had endeavoured by the application
of physical methods to show this. A study of a large number of family pedigrees had
shown that psycho-neuroses and psychoses were found in various members of a stock
often endowed with genius or high intellectuality. This fact he (the speaker) regarded
as evidence of an inborn tendency to neural instability affecting neuronic structures of
the highest and latest evolutional level. He wished to express his appreciation of the
valuable researches carried on by Dr. Golla at the Maudsley Hospital during the
last three years. These researches had the great merit of being an addition to
knowledge upon a subject of which very little was known owing to the many technical
difficulties encountered. He was sure that Dr. Golla would be the first to admit
how little was known and how much there was to learn before the system of
physical methods of measurement could be applied to the objective study of mental
processes and utilized in clinical diagnosis, but he (the speaker) was convinced
that the methods Dr. Golla had employed were a step forward in the right direction.

Dr. Crichton Miller said that he had been much interested in Dr. Golla’s paper,
and recognized the amount of painstaking research represented by its findings. For
his own part, however, he felt that so long as they restricted themselves to the
observation of neurological reactions, they were only contributing to the diagnostic
side of the work. Sir Frederick Mott’s remarks about heredity had also considerable
value, but that again was largely limited to prognosis. Treatment must ultimately
depend upon the conception of individual aetiology; and for that they would constantly
find themselves confined to tw'o great categories : (a) the bio-chemical, covering the
endocrine factor ; and (b) the psychological, covering emotional conflict.

Section of Psychiatry

Dr. Golla (in reply) said that he feared he had failed to make it sufficiently clear
that the investigations which he had put before the Section were solely directed to the
demonstration of the organic disturbances underlying and preceding the establishment
of a neurosis. It was obvious that the actual orientation of the particular neurotic
symptom was determined by the preceding psychical events. Such investigations as he
had here put before them admitted of no direct application by the clinician. In years
to come it might of course happen that the groundwork now being slowly accumulated
would bear some practical fruit.

Section of Ip0\>cbiatrs.

President—Dr. C. Hubert Bond, C.B.E.

The Use and Abuse of the Relationship between Doctor and
Patient in the Practice of Psychotherapy.

By Mary C. Bell, M.B.

Any understanding I may have upon this subject is mainly the outcome of
observations made in my own hypnotic and analytical practice, of my own
reactions to my analysts, and of my knowledge of the writings of psycho¬
analysts, but that does not mean that the subject is only of value from the
psycho-analytical point of view. The relationship between doctor and patient
is of primary importance in any psychotherapeutic practice, whether that of
hypnotism, persuasion, re-education, or analysis.

The personality of the doctor as an asset in the building up of a successful
practice is recognized in the term “ a good bedside manner,” and the man who
could inspire confidence without causing irritation, and would save his patients
trouble by dictating a pleasant course of future action, was almost sure of a
large clientele. But this is a rough and ready method compared with the
finesse needed in the more prolonged and infinitely more intimate relationship
of psychotherapy. To give one instance only of the change : the older doctors
were very willing to assume responsibility for their patients: to say, “ come
here,” “ go there,” “ take up such and such work,” “ go for a sea voyage.”
The tendency now is to encourage independence of thought and action on the
part of the patient: to impart wisdom instead of demanding submission; and
this necessitates a knowledge not only of the strong and weak points of the
patient’s psychology, but also of one’s own.

I will first put the problem from the patient’s point of view, and then from
that of the physician; finally I will make suggestions with regard to the
conscious handling of the relationship between the two.

The patients are like frail vessels embarked on a great adventure, an
unknown quantity being the doctor. Like all of us, they have made mal-
adaptations to life, and though they may recognize and acknowledge the gross
results of the mal-adaptations they do not see where the kinks originally
occurred, since those arose in early childhood. Given a certain environment,
a child with a certain temperament will react in a given way. The original
mal-adaptation was an innocent enough affair, but the gross results are
weighed against the often distorted standards of conventional herd thought,
and the patient becomes burdened by an overwhelming and crippling sense of
shame; for conventional standards are regarded as absolute authority, and
thereby invested with too great a value.

[December 12, 1922

Section of Psychiatry

Many of the difficulties in life arise from the discrepancies between the
unconscious standards and over-valuations that we make for ourselves or adopt
from others, and the standard to which we are capable of attaining in reality.

Now in order to understand the attitude of the patient to the doctor, we
must consider the problems of projection and identification. By projection
I mean the unconscious placing of our own thoughts and phantasies outside
ourselves, and the failure to recognize them as our own. We all recognize
striking examples in the projections of paranoia, but we do not always realize the
great part played by projection in everyday life. For example, a mother crossing
a field containing cows is afraid, and thinks that her child is afraid ; a father
projects on to his son his own desire that the son should take up a certain
career; or a person who is not very truthful is surprised at the deplorable lack
of honesty in his friends. In one way or another a great number of our own
unrecognized psychological tendencies are projected in the form of criticism.

By identification I mean the actual psychological union of oneself with
one’s ideas and dreams, with emotions, or with surrounding objects. The child
not only acts the princess or hero, but is the princess or hero, and demands
suitable treatment and reverence from nurse and companions; the nun not
only adores the Christ, but is the Christ, and develops the stigmata of the
crucifixion; the politician is identified with the creed of his party, and any
attack upon his party is an attack upon himself. It is identification with ideas
and feelings that is of such great importance to us. If we are not identified we
can stand aside and see the idea or emotion in its right proportion and judge
dispassionately. The child who is not identified with the princess or hero
can distinguish the phantasy from the reality, and the phantasy does not
permanently affect her outlook on life, but the woman who is still identified
w'ith her “ princess ” or “ perfect lady ” phantasy unconsciously expects from life
the deference she imagines a princess would receive, and then she is dissatisfied
with and refuses to accept reality.

Now these processes of projection and identification both take part in the
relationship of the patient to the doctor: unrecognized attitudes and desires
are projected on to the doctor and form the basis of a positive or negative
relationship, or transference, as it is called. All of us are more or less under
the sway of unrecognized infantile reactions : in certain situations, peculiar to
each one of us, we meet the problems of adult life with the emotions or
thoughts of infancy. In the type of patient coming to our consulting rooms this
discrepancy between the problem and the understanding of it is peculiarly well
marked : and although, in many cases these patients may have an intellectual
appreciation of their defects, they do not feel them in their “bones,”
or see their manifestations in life. For instance, a friend of mine, in spite of
having led an apparently full and busy life, had always asserted, to the amuse¬
ment of her friends, that she was born lazy. That was a true, but purely
intellectual appreciation of a certain aspect of her psychology, but it is only of
late years that she has understood it sufficiently to observe its very subtle
manifestations, and to attempt to eliminate her laziness. In the same way
our patients have partial realizations of their defects and desires, and this
knowledge of themselves clamours for conscious recognition; but the buffers
associated with pleasure and pain, and inculcated ideas of morality, prevent
them from acknowledging the desire or the defect. Now a vague feeling
that someone is lazy, or childish, or cruel, cannot continue unattached;
and as barriers hinder it from coming home to roost, it is projected into the
environment, and in most cases, during psychotherapeutic treatment, it is

14 Bell: Relationship between Doctor and Patient

the physician who becomes the perch. Naturally this is more noticeable
in treatment by analysis when the patient is being encouraged to recognize her
own birds and bring them home to roost, than in repressive treatments such
as hypnotism and the method of Cou6, where the birds are merely shut up in an
incubator out of sight; but even in these treatments projections may become
a barrier.

A patient, aged about 40, comes into my room and says, in a childish way,
“ I have not brought you any dreams, doctor, I’m afraid you will be annoyed.”
“Why should I be annoyed?” I say: and then after some search I find that
the patient is projecting on to me her fear of one or other parent, usually,
in my case, the mother, or of some governess or mistress in the past. Or
the reverse occurs: the patient who has suffered from too little love and
understanding in childhood has built up an imago of the perfect mother, and
wants to sit at my feet like a child ; moreover she unconsciously judges all
women by this perfect standard. Now both these types will fail to progress if
their attitude to me is not discussed and understood, for how can an adult
child who has been unable to give confidence to her own mother have
confidence in me if she is unconsciously expecting me to sneer at or
misunderstand her? or how will she grow up and become independent and
willing to bear her burdens in life if I let her go on sitting at the feet of
a mother imago ? It may be the father who has kept the child bound, in some
cases choosing a career for her, and then she will persistently invest the
physician with the status of father-counsellor, or, it may be, lover.

Or perhaps the patient has to recognize some kink*of untruthfulness, or
cruelty, or untidiness, &c.; and then we may be told we are not so truthful as
we might be, or that we take a cruel pleasure in dissecting our patients, or that
we dress badly. Or the patient may be dealing with unrecognized sex desires,
and these, too, may first announce their approach by some homosexual or
heterosexual attitude to the physician, a projection that is often violently
resisted by the patient.

Megalomanic ideas, on the other hand, may lead to identity with the
analyst; the patient thinks he can get on with his own treatment, or tries to
analyse the doctor. Very often the relationship of patient to doctor is a mixed
relationship, alternating from positive to negative and back again. For
example, I had a patient with a definite positive transference, who periodically
became distinctly negative, saying I was cruel, and forced her to do things she
was quite unable to do—to turn up punctually at my consulting room when she
was “ feeling all anyhow.” She suffered from very constant attacks of nausea,
and a feeling of a wedge in the back of the head since she was 9 years old
until her present age (37). Part of the negative transference disappeared when
she realized that she was identifying me with her older step-sisters, who when
she complained of feeling sick in childhood used cheerfully to say: “ Oh ! no,
you don’t—come along! ” thus causing her much uncertainty about the veracity
of her own feelings. Another, the patient of an absent colleague, had a very
marked negative attitude underlying a childish adoration—she felt my colleague
as an awful power, who expected all she said to be accepted as gospel truth—
this was partly a projection of the patient’s own power psychology, and partly
a projection of the difficulty experienced by her irrational infantile psychology,
in accepting the very rational psychology of her family. Common sense
appeared to her like a Juggernaut. We must remember that these projections
are phantasies, the imaginings of a distorted outlook, and in no way indicative
of the true state of any situation. And so, as I have said, the patients’

Section of Psychiatry

birds come home to roost on the “ doctor perch,*’ though cases do occur in
which the bulk of the transference goes over on to some relative or friend.

Now we must approach the problem from our own point of view. Every
relationship is reciprocal; we think a great deal of the patient's contribution,
but perhaps we do not enough consider our own share. We, too, are the
victims of unconscious infantile reactions ; some of us have honestly tried
to eliminate, as far as possible, their effects, by undergoing a long analysis
ourselves ; some of us, perhaps, have not, and any reaction we have not yet
understood in ourselves we may project on to our patients, and the beam in our
own eye will prevent us from seeing the motes in our patients* eyes.

I have heard psychotherapists say that “ there is nothing in the trans¬
ference/* They stand self-condemned, for nobody who has been analysed by
a competent analyst can fail to understand the delicacy and working value
of the relationship; the resistance of the so-called self-analyst to analysis
by another person is proof of the activity of reactions that must put
up a barrier between physician and patient, and these barriers will keep the
work on a superficial plane. To mention one barrier only. The patient who
realizes after a time that the physician has not himself been through this
exacting and heart-searching ordeal—and I have more than once heard this
criticism made—is apt to resent the self-knowledge gained through one who
searches, but will not be searched; and I have known cases in which the
physician’s lack of understanding of his own psychology, a lack of under¬
standing that was apparent to the patient, has converted a good relationship
into a bad one, with subsequent rupture of the treatment.

It may be argued that the leaders of the two main schools of psychological
analysis had no one to analyse them. That may be true ; but in spite of that,
they recognize the relationship, and the danger or value of it as the case may
be; and one of them, at any rate, Dr. Jung, of Zurich, has utilized the
relationship to make good the absence, in later years, of an analyst for
himself. For, the relationship being reciprocal, it is possible for a sincere
worker to analyse himself by his reactions to his patients and their
criticisms; but it is a sine qua non that in order to do this, he must
recognize that there is such a thing as a relationship, and of what the
relationship consists.

The patient looks at the doctor through spectacles the lenses of which
are the varying projections of unrecognized psychological identifications which
may produce a highly distorted image, and the doctor does the same by the
patient. If in a day’s work with six or seven patients I find it necessary to
discuss the same problem with more than two of the patients, I begin to take
stock of my own psychological problems, and to inquire of myself whether I
am seeing clearly, or whether I am distorting my patient’s problems by my
own. It is possible that two patients in a day may be dealing with the
same problem, but three patients I regard as a warning to myself. When
every patient seems to us auto-erotic or obsessed with sex, we must take heed
to our own psychology. When every patient brings me a different problem, I
take it for granted that my own lenses are fairly clear. We must not
project on to our patients intuitions concerning our own psychological state.
Recognized as belonging to ourselves, these intuitions are most valuable—
projected on to a patient to whose psychology they are alien, they are cruel and
devastating, and may change a positive into a negative relationship. The
patient who knows nothing of projections will try to fit them on to his own
psychology, or realizing their falsity but unable to formulate his realization,

Bell: j Relationship between Doctor and Patient

will develop a negative attitude, and be unable to proceed with or benefit by
the treatment. In the purest form of psycho-analysis where the analyst acts
as a mirror and no form of discussion of the patient’s problems takes place,
presumably the risk of projection by the physician is small, but in any form of
treatment by discussion or persuasion, and in the actual diagnosis of the situa¬
tion, the unrecognized projections of the physician may play no inconsiderable
part. Indeed, projection is a prime factor in ail human relationships. If all
of us could see one another clearly without any blurring from our own pro¬
jections, how much more just should we be, and more tolerant of one
another. I think I have found in my own experience that people with a
highly developed faculty of intuition are particularly prone to experience
intuitions concerning their own psychology, and to project them on to
others.

The psychology of the physician will also affect the handling of the
patient, and the method of treatment employed. A person with an unrecog¬
nized power or authority complex will tend to keep the patients in an inferior
or infantile condition, and will manage them and dictate to them too much,
and so unconsciously prevent them growing up. In those cases patients will
return again and again for a spell of help, because they are not made to realize
that they are still dependent on authority and the protector. I think, too,
the doctors with an unrecognized power complex will tend to make use of a
rather dominating form of hypnotism in their practice, whether as pure
hypnotists or as analysts employing the hypnotic cathartic method of analysis.
There must be a danger that their patients will only slowly free themselves
from the relationship and grow up. I use the term “ growing-Up ” as ex¬
pressive of an adult adaptation to life ; we should be just our age ; neither too
young nor too old ; any precocity or retardation is a mal-adaptation to the
law of normal development; but every person has his own rate of growth.
Now, having recognized the patients contribution to this relationship and
our own, how must we handle it ? Are we to take the patient’s liking as a
good sign, and leave it at that, or skilfully turn the patient down if there is
dislike, which may be mutual ? Emphatically no ! The relationship must be
used as the pivot of the treatment, as the sensitizer for determining the measure
of the patient’s progress, and sometimes as the one prop to which the patient
can cling when he suddenly sees life as illusion, and is groping in the dark
for material with which to build anew.

So in the first place the physician must be willing to accept the relation¬
ship, in all its intensity if necessary, as a temporary splint. Some analysts
tell their patients that they will not have them falling in love with them—you
might as well refuse to offer a finger to a baby who is learning to walk, it
would be as rational. With patients who are not very ill because their
adaptation to reality has been fairly good, there is not much need of the
splint; they, as it were, have only a sprain. But in the very bad cases where
reactions have been entirely infantile, and contact with reality has been
prevented by a life-long screen of phantasy, the patient literally does not know
where or to whom to turn when the screen has been destroyed; he is like the
healed .blind man who saw men as trees walking; everything is out of
perspective, and until his vision has accommodated to the new conditions he
needs must have a prop. A careful building up of the positive relationship at
the beginning of treatment may save patient and physician from a catastrophe
as the reductive analysis proceeds. Some may ask if it is necessary to pull
down the screen of phantasy, but often it is life itself that has destroyed the

Section of Psychiatry

screen, and the too sudden smashing down of buffers in a person with small
capacity for adaptation is the cause of the neurosis; then the physician is the
one fixed point to which the patient can cling until he has gained the sense of
his own solidity.

This building up of a transference needs courage and sincerity on the part
of the physician. Our natural reserve does not make it easy for us
deliberately to ask our patients what they think of us. Some patients, of
course, discharge their own feelings of psychological discomfort in biting
criticisms of the doctor; others again are too shy to be honest in their
criticisms, and have patiently to be shown that a frank expression of their
like or dislike of the doctor is part of their contribution to the treatment, as
the wishes and fears projected on to the physician reproduce forgotten
attitudes to ideas and people important to them in the past. It is not easy to
face the full blast of a negative transference when we are subjected to
accumulated long repressed feelings and ideas of a very unpleasant nature;
but our own discomfort must be merged in the realization of the still greater
discomfort of the patient, and of the urgent need of bringing such feelings out
into the open, lest after further repression and accumulation they emerge at
length with insane—perhaps paranoic—force. The doctor must remember,
too, that any criticism may not be wholly a projection of the patient’s
psychology; it may also be a true criticism of the physician. Our patients
may be ill, but many of them are by no means fools, though perhaps it is
easier for us to realize that fact from the very pertinent remarks they make
about other physicians whom they have visited, than from their criticisms
upon ourselves. But if we recognize the criticism as true of ourselves, and
are not ashamed to avow it, barriers may be destroyed, and progress hastened,
whereas a refusal to discuss the criticism may perpetuate a feeling of distrust,
and a sense of inferiority on the part of the patient. It is practically a
continuation of the adult attitude to children, “ You must not say that to
father, it’s rude.” Sometimes the criticisms show that it is advisable to alter
one’s manner to certain patients, to become less calm and more aggressive, for
example, or to appear stupid, in order to make a lazy patient work.

And, lastly, the physician must welcome and encourage the growing
independence of the patient. It seems'to me the patient is trying his new¬
found wings at the expense of the doctor. In youth he is always under
authority; people may criticize him and be rude to him, but he must not
answer or be rude in his turn, or he must not talk about things of great
interest to him; he is perpetually competing against people of greater
physical and mental capacity than his own (this is especially noticeable in
the case of the youngest children of large families, who, in my opinion, are
more to be pitied than only children), and he is perpetually competing against
his own over-valuation—repressing here, and striving there—and then, at
last, he meets with someone who regards him, and expects, in essential
matters, to be regarded by him as an equal struggling along the path of life;
who sees him as un-understanding perhaps, but not a hopeless failure; and
so, gradually he begins to take the doctor at his word, testing each new
adaptation by its effect upon the physician, for the measure of his relationship
to this teacher is the measure of his relationship to the world; if he can talk
and behave as an equal to his doctor, surely he can meet the world on equal
terms. And so, his old infantile reactions having been projected on to the
doctor, accepted calmly by the doctor, discussed and understood, he finds
himself at last face to face with him as an adult, and can replace his original

Bell: Relationship between Doctor and Patient

infantile attitude by an ordinary human relationship between two adult
beings. And as these adaptations proceed, we notice changes in the patient.
We feel that we are talking to an equal and not to a child. The face of
an infantile patient will become the face of a woman in a few weeks of treat¬
ment, lisps and high-pitched voices disappear. In short, the patient, having
found and accepted her own hole, instead of thinking that everybody else’s
hole is better than her own, no longer needs all the camouflage and
mannerisms of the past.

I have taken the relationship mainly from the point of view of the analyst,
but naturally it affects the situation in hypnotism and re-education.

I have spoken of the possible tendency on the part of a physician with an
unrecognized power-complex, to dominate his patients too much, and unfortu¬
nately some patients with a parent-complex like to be dominated ; they prefer
the attitude of the sleeping child to the protecting parent, or perhaps of the
woman to the more dominating male; they do not want self-revelation, and
the stress and struggle of re-orientation to reality; “ Rocked in the cradle of
the deep, I lay me down in peace to sleep” is their attitude to life, and their
dependence is not lessened by hypnotic treatment alone. Other patients, on
the contrary, those with an authority-complex, dread the apparent self¬
surrender to, and domination by the hypnotist. In the past, many patients
have told me they did not want to be hypnotized, and had I overpersuaded
them, they would almost certainly unconsciously have resisted my efforts:
but when they realized it was purely a technique, and that by following my
directions they could put themselves into a state of receptiveness without a
word or movement on my part, they readily gave me permission to deepen the
self-induced hypnosis, and to reinforce their suggestions.

Hypnosis appears to be a means of increasing our identification with a
given idea, so that more and more we come under the unconscious domination
of that idea, and are therefore less our own masters. If the reinforced idea
produced an unpleasant instead of a pleasant feeling tone, we should call it an
obsession. This increase of identification with pleasant imaginative ideas I
believe to be the rationale of the Coue system : whether it leads towards
individual psychological freedom is a doubtful matter.

I am glad to have had the opportunity of introducing this subject for
discussion as I am convinced that a great deal of the distrust of the transfer¬
ence is due to sheer misunderstanding. Having worked under three well-known
analysts and come safely through a negative transference to one of them, and
having previously had considerable experience in hypnotic and re-educative
methods of treatment, I can speak from practical experience. I have often
been distressed at the view of the transference expressed by the medical pro¬
fession and the lay public. A few months ago a patient told me that she had
been to a lecture the day before in which the lecturer had said that everyone
must fall in love with the analyst, and she did not want to fall in love with
me. As a matter of fact, I was able to show her a few minutes later that, far
from falling in love with me, she had a slight negative attitude towards me as
she was identifying me with a head mistress of whom she had been afraid
w T hen a child. When she became conscious of—and understood—this negative
attitude to me, it disappeared.

In the British Medical Journal of December 2, 1922, I read the following
in a review of a book on Crime and Analysis:—

” The possible, or even probable, risk during the process of psycho-analysis of the
transference of the patient’s feelings towards other persons (whatever the feelings may

Section of Psychiatry

be) to the psycho-analyst himself is strongly emphasized by the author. 4 It will be
seen/ he writes, ‘ that psycho-analysis is a method of great difficulty, requiring know¬
ledge of a special technique, much experience, and perhaps certain gifts which are not
possessed by all. It is a trying process for the psycho-analyst; until an attempt has
been made no one can conceive what a severe strain this method is.’ ”

Then the reviewer goes on to say :—

“ One reflection following on the reading of these words of his is that a very small
proportion of men or women doctors could possibly be expected to combine all the
qualities necessary to practise psycho-analysis properly, even were its soundness, as
based on science, and its successful application in practice, to be generally admitted.”

I accept the words “ the possible, or even probable risk/* just as I accept
the possible, or even probable, risk arising from the administration of an
anaesthetic if given by an insufficiently skilled administrator: in both cases,
the risk is proportional to the skill of the administrator and the concentration
of the drug, and it is lessened by the due administration of air. If the
feelings are projected on to the physician in bulk, and are allowed to accumu¬
late and fester without ventilation or relief, I admit the risk; and that is why
one should be as careful in the choice of an analyst as in the choice of an
anaesthetist. But if the relationship is kept as a pressure gauge between the
two, it becomes an indicator of safety, and forms no abnormal tie when the
treatment is over, whereas in hypnotic work the relationship is not discussed,
and I have seen violent transferences occur. The same emotional situations
arise between priest and penitent in the religious world. Try how you will,
you cannot prevent such relationships, and therefore it is much wiser to keep
them well ventilated, and to make of them an instrument and not a risk.

DISCUSSION.

Dr. CRICHTON Miller said that Dr. Mary Bell had admirably expressed the Zurich
view of the transference but he felt that she had not made it sufficiently clear that
transference might take the form of any sort of relationship; not merely that of the
child to the father or mother, but of brother to sister, brother to brother, and so on.
In fact, any conceivable human relationship could be represented in the transference.
The aim of the analyst should be to transform transference to the relationship of the
climber to the guide, and to eliminate the element of authority progressively.

Dr. H. G. Baynes said that having recently spent three years in assisting Dr. Jung
his remarks might be regarded as representing Jung’s present standpoint on the question
of transference. Jung, he said, looked upon the transference as the dynamic factor
underlying the whole analytical process. The analyst reaped the advantage of this
energic value not from any special personal value he might possess, but because he
represented the possibility of a new attitude. Hence he appeared as a function of life,
thus becoming associated with the figure of father, husband or priest, whose psychic
archetypes gained their energic value from the same fact. Since the aim of the libido
was transformation and expression the analyst was bound up with the whole complex
of metamorphosis, and the nature of the transference determined the nature of the
analytical transformation. The transference, Jung held, was inherent in the analytical
process and quite outside the analyst’s intention. This being so, the analyst could not
evade the responsibility it entailed. If the responsibility was admitted, the further
problem of individual development could not well be avoided, carrying with it the
need of investigation, and, if possible, formulation of the principles of human develop¬
ment. Since no interpretation of any sort was possible without a standpoint, Jung
maintained that criticism of standpoint was more essential than criticism of method.

Bell: Relationship between Doctor and Patient

The transference might be regarded, then, as the life-values of the libido seeking
expression in the form of human relationship. Although fundamentally instinctive*
the transference only took a frankly sexual form as a fante de mieux when the more
conscious and synthetic relationship was either denied or ignored. When individuation
was accepted as a conscious and deliberate aim on both sides, the purely instinctive
quality of the transference quickly disappeared. The only cure for the positive trans¬
ference was to transform it into individual relationship. In this relationship- the life-
values that were seeking expression in the blind instinctive transference attained con¬
scious appreciation and recognition. Hence the sincerity of the analyst was a factor
of greater moment than the particular method employed.

Dr. Mary Barkas said that the remarks of the previous speaker showed clearly
one of the fundamental differences between the schools of Jung and of Freud—namely,
that Jung believed that the analyst should impose his own ideals of moral values and
personality on the patient, whereas Freud held that the analyst should be a neutral
person, acting like a mirror in reflecting the patient to his own sight, and being guided
entirely by the workings of the patient’s own psychology.

Dr. W. A. POTTS said that he also had noticed the importance Freud attached to
re-education in his latest work, “ Introductory Lectures on Psycho-analysis ” ; he also
noted that Freud said that repressions should be dealt with by suggestion. Dr. Potts
concluded therefore that Freud’s method was to drive his own ideas home; so that it
seemed at first as if he had deserted his own school. On further reflection Dr. Potts
thought this was not the case, because recently at a medical meeting, where most of
those present were Freudians, when he (Dr. Potts) had said that psychological analysis
achieved its end by giving more light, his hearers had insisted that any good done must
have been effected by suggestion. Dr. Potts could not agree with Dr. Bell that it was
ever right to “ act ” ; the analyst should always be natural and just himself; nor could
he agree that intuition necessarily led astray ; at any rate he knew how useful intuition
had been in his own analysis, and he also knew that in the case of some of his own
patients it had not led him astray; he thought intuition should be developed.
An objection had been made to going to a personal friend for analysis, but he (Dr. Potts)
supposed there were different points of view, because recently after he had given some
lectures to nurses on this subject, one of them said she would like to have such
treatment, except for the reflection that it meant telling intimate facts to a stranger.
His (Dr. Potts’s) experience had been that there was no special difficulty in taking an
acquaintance as a patient, but he felt that it would not be wise to try to treat an
intimate friend.

Section of l>s\>cbiatn>.

President—Dr. C. Hubert Bond, C.B.E.

The Endocrine Factor in Mental Disease.

By J. Leitch Wilson, M.B., D.P.M.

ENDOCRINOLOGY has been prominent in recent years in every branch of
medicine, and its relation to mental disease was discussed at the meeting
o the Medico-Psychological Association in Edinburgh, July 1922.

Sir Frederick Mott, especially, has excited the interest of all students of
mental pathology, by his discoveries with reference to the sex glands in
dementia prsecox, and in recent papers he has laid stress on the importance
of the internal secretions as factors in all mental disorders.

The recent researches of Cannon [l], by which he has demonstrated a
change in the internal secretions as one of the results of an affective state,
and the work of Golla [2] in investigating the various objective signs of the
neuroses, show that the present tendency is to make some attempt to
correlate the work of the psychologist with that of the physiologist.

Unfortunately in our special branch of medicine a great deal of careful
research as to the causation of mental troubles has been lost to science
because of the schism between the psychogenetic and the phvsicogenetic
schools. This schism is due to the fact that their efforts can never be
collaborated to advance our knowledge so long as they are expressed in
different languages. The technical terms and the findings of the psycho¬
logist can never be tested at the post-mortem table nor up to the present has
the materialist been able to explain human behaviour in terms of neurones and
dendrites. Now, however, with the work of Cannon and Golla showing
methods by which the state of the mind may be tested objectively, a new era
has arisen in the study of mental pathology, and it is from this point of view
that I have chosen as the subject of my paper, “ Endocrines in Relation to
Mental Diseases.” I am fully cognizant of the difficulties of the subject, but
I hope it will be remembered that our choice in mental science lies between
an attempt to explain psychical symptoms on a physiological basis and an
acceptance of the purely speculative concepts of psychology.

The Biological Relationship of the Endocrine System.

The endocrine glands may be defined as certain specialized glandular
tissues—widely distributed in the body—which pass their secretions directly
into the blood. Each of these internal secretions has a specific stimulative
or inhibitive effect on the metabolic processes, differing according to the gland

Ap—Ps 1 [January 9, 1928.

22 Wilson: The Endocrine Factor in Mental Disease

of origin. There is, however, such a close inter-relationship between the
endocrine glands that their secretions act physiologically in concert, forming
what is known as the “ endocrine balance.” The principal glands usually
included in the system are the pituitary, thyroid, parathyroid, adrenal bodies,
pancreas and gonads, and to these may be added others such as the thymus,
the pineal body, the glands of the intestinal and gastric mucosa, &c., as better
knowledge of their functions becomes available. Ontogenetically, most of these
structures appear from the fourth to the sixth week of foetal life, the anterior
or buccal part of the pituitary gland being the first differentiated. With regard
to the adrenal body, Keith [3] says that “ although arising from the blastema
of the sympathetic system it is differentiated before the nerve cells of that
system as if it represented the product of an earlier evolution.” Phylogeneti-
cally, as the endocrine system produces its effects by chemical activity, it
appears to have a morphological relationship to a similar system in primitive
forms of life—where the linking up of the various chemical products, by a
circulatory apparatus, fulfils, in the absence of a nervous system, all the
adjustments necessary to adapt the organisms to its environment. Jeliffe [4]
holds that the endocrinous gland system is phylogenetically the oldest part of
the vegetative nervous system. Langdon Brown [5], in a biological study of
the endocrines, concludes that 14 the internal secretions result from the special¬
ization of the old chemiotactic mechanisms to which primitive animals reacted
before there was a nervous system at all.” Loeb [6] has shown that even
in more highly organized animals such as bees and wasps, possessing a nervous
system, the instinctive behaviour may be heliotropic in character. In certain
caterpillars the motions of the legs are automatically controlled by the chemical
changes taking place in symmetrical elements of the retina under the influence
of light. So that, even in the presence of a nervous system, the real adaptation
of the creature to its surroundings may still remain under the control of its
chemical activities.

Carpenter [7] describes the Ascidian mollusc as illustrating the simplest
form of nervous system consisting of a single ganglion with afferent and
efferent fibres. Its function is to prevent noxious particles from entering
the pharyngeal sac by a sudden contraction of its muscular envelope in
order to expel the contents of the sac. Here we have an illustration of
three principles which still apply to all forms of life : (1) That a rapid

response to noxious stimuli is the first necessity for continued existence;
(2) that the whole vital power can be mobilized for self-defence ; (3) that
nutrition is interrupted under the imperative need of self-preservation.

It is interesting also to note that, in the primitive form, the nervous
system is first developed for the purpose of preserving the organism from
injury, because, when an attempt is made to trace the relationship of the
endocrine system to the nervous system in vertebrates the connecting link
is found in the chromaffin tissue of the adrenal medulla, an organ prima¬
rily related to the defence mechanism of the body.

The question then arises, in view of the enormous development of the
central nervous system, to what extent it has taken over the duties and
responsibilities of the older chemical or glandular system, and whether the
older system, while delegating to the more efficient machine all the fin6r
adjustments and adaptations of human behaviour, may not have preserved
to itself the orientation of the whole organism, in subserving the primal
instincts of nutrition, self-preservation, and propagation of species.

In an attempt to estimate the comparative functional value of the two

Section of Psychiatry

systems, we know from our study of physiology and neurology that, from
the simple reflex to the highest intellectual development, the nervous system
tends to automatic machine-like action. In a simple reflex the appropriate
stimulus will always produce the same quality of response. In conditioned
reflexes, which involve the association areas, the same stimulus will go on
producing the same response until a new association is formed. There is
always a tendency to the formation of habit mechanisms and even habits of
thought processes. Neurologists know that certain tracts have specified func¬
tions and when these tracts are destroyed by injury or disease their func¬
tions are definitely lost and on this principle the diagnosis is based. Sher¬
rington [8] has shown that the most recently developed cortical areas of
the brain are stereotyped as to function ; and Darwin [9] has pointed out
that emotional expression in man and animals is automatic in its character.

On the other hand the endocrine system with its constant ebb and flow of
chemical activity, its intimate connexion with all body metabolism, and its
close relationship with the nervous system, seems more fitted to be the
originator and controller of that wonderfully complex ever-changing syndrome,
human conduct.

In a study of the basis of behaviour it may be helpful to quote the view of
a modem psychologist. McDougall [10] says:—

“ I am convinced that it is only ... by recognizing the essential similarity of
human instincts to those of animals . . . that the continuity of the human with the
animal mind can be displayed, and that a science of human character and will can be
built up.”

And he defines instinct as follows :—

“ Each innate specific conative tendency has at its service an innately co-ordinated
system of motor or efferent nerve channels: . . . these belong together functionally
and phylogenetically as one feature, one psycho-physical disposition of the inherited
constitution of the organism : . . . each implies the other; . . . instinctive activity
always involves their co-operation: and ... of the two the conative tendency is the
more essential and fundamental feature of the total innate disposition which is
the instinct .”

There are some indications that, b 3 ' a study of endocrine physiology the
physical basis of the “ innate specific conative tendencies ” may be found,
just as the “ innately co-ordinative system of motor or efferent nerve channels M
is based on the nervous system. I propose therefore to discuss the functions
of the various internally secreting glands in relation to the primal instincts of
nutrition, sex, and preservation from injury.

(1) Endocrines governing Nutrition .

The pituitary gland has the peculiarity of being the least accessible and
best protected gland in the body. Its extirpation in animals is followed by
death in two or three days, whereas decerebrate cats—where all the brain
in front of the pons is removed—can be kept alive in some cases for three
weeks (Bazett and Penfield [11]). In man hyperpituitarism as associated
with adenoma of the anterior lobe presents the remarkable phenomenon of
acromegaly—a gradual anabolic change which alters the whole physiognomy
of the affected person by heterogeneous development of certain structures.
The brows become prominent, the malar bones and lower jaw are increased
in size, the tongue and lips are thickened. There is enlargement of the chest;

Wilson: The Endocrine Factor in Mental Disease

the heart, lungs, arteries and veins hypertrophy, and the renal substance is
increased. The most typical effects are seen in the hands and feet, which are
uniformly enlarged—bones, joint surfaces, ligaments and muscles. Keith [12]
calls this disease a “ disorderly manifestation of all the results which follow
increased use of muscle-bone strength.” There is also some evidence that
gigantism is caused by hypersecretion of the pituitary gland in early life.
Here is an example of a gland which, by its excessive function, appears
to exercise on the anabolic processes of the whole body an intelligent co¬
ordinating influence, over a considerable period of time, producing a new type
of human being.

On the other hand, when a part of the pituitary gland is removed from
young animals they fail to develop properly; milk teeth and lanugo are
retained, epiphyses do not ankylose, the thyroid and thymus are enlarged,
the cortex of the suprarenal bodies and the sexual organs fail to develop,
the animal becomes fat and there is distinct evidence of mental dullness
(Macleod [13]).

Another interesting point is the enlargement of the pituitary to two or
three times its size in pregnancy just at the time when the foetus is being
nourished in utero and when there is going on in the mother a definite
purposive anabolic change affecting the circulatory, skeletal and reproductive
systems.

The thyroid gland , like the pituitary, shows increased function during
pregnancy, and also when there is loss of pituitary substance. There is
hypertrophy of the pituitary in thyroid deficiency. The powerful influence of
the thyroid on growth and development is so well known that only a brief
reference is necessary. The stunted growth of body and more particularly
the lack of mental development caused by insufficiency of its secretion, and the
restoration of normal conditions by thyroid feeding, furnish one of the most
potent arguments that glandular activities are the physical basis of our
instinctive tendencies. In the complete absence of thyroid in early life there
will be no mind—in other words idiocy. Then again, it is necessary that this
gland should function throughout life to preserve mental power, for if with¬
drawn in later life myxoedema arises, causing a gradual approach to dementia.

The adrenal cortex is also associated with body growth. It has been
shown [14) that in the human foetus there is a great development of the
innermost part of the cortex which gradually disappears after birth—and that in
anencephalv this zone is absent—a fact which suggests that there is probably
a causal relationship between the adrenal cortex and brain development. This
gland is also enlarged during pregnancy. Its removal is incompatible with
life as shown in recent animal experiments by Wislocki and Crowe [15].

The pancreas , through its internal secretion, insulin, also takes part in
anabolic activity and the pineal gland is said to exercise a restraining influence
on sexual development during the stage of growth in childhood.

(2) Endocrines directing Sexual Development .

The relationship of the internal secretions of the gonads to the physical
conformation of the adult male and female has been the subject of a great
number of experimental investigations of recent years. It is now generally
accepted that the testis, by the production of an internal secretion, causes
the development of all the secondary male sexual characters. The ovarian
secretion helps to develop and maintain the secondary female sex characters

Section of Psychiatry

such as the growth of the uterus and mammary glands, and also determines
the onset of menstruation. The most important effect of these secretions,
however, is evidenced by a profound alteration in the mental outlook, the
beginning of a new epoch during which the emotional capacity is enormously
developed. The brief outbursts of joy, sorrow, chagrin and anger which swiftly
appear and disappear in the child, become at puberty the more lasting moods
of exaltation, depression, anxiety and bad temper with occasional storms of
extreme hilarity, morbid impulses, anguish and angry passion.

While the gonads are primarily responsible for all these changes, there
is much evidence to prove that other glands, the adrenal cortex, the thyroid
and the pituitary, play an important part in sexual development. There is
ample proof that the causal factors of all phases of sexual activity may
be found in the endocrine system.

(3) Endocrines concerned in Self-preservation.

That the adrenal medulla plays a very important part in the defence
mechanism of the body has been demonstrated by the experimental injection
of adrenalin into an animal intravenously. The effects produced are consistent
with a general stimulation of the sympathetic division of the vegetative
nervous system. There is raising of blood-pressure, increase of rate and
amplitude of the heart’s action, withdrawal of blood from the abdominal cavity
to increase the skeletal supply, thus insuring a better blood supply to the
voluntary muscles. The bronchioles of the lungs are dilated to allow of an
increased respiratory exchange. The glycogen stores of the liver are tapped
to increment the blood sugar preparatory to more efficient muscular action,
and from the same organ comes a substance which hastens the clotting of the
blood in case of injury. The pupils of the eyes dilate to facilitate visual
observation. The sweat glands are stimulated to keep the skin cool in action,
and finally there is an interruption of the digestive processes due to the
inhibitory effect on the smooth muscle of stomach and intestine. Thus we
have a clinical picture of the whole organism adjusted to the best advantage
for the purpose of offensive or defensive action. Cannon [16] has demon¬
strated by animal experiments that psychical stimuli producing physical signs
of the major emotions (pain, fear and rage) cause a physiological secretion of
adrenalin into the blood as one of the visceral changes which accompany
the emotion.

The thyroid gland also takes a part in the bodily reaction to noxious
stimuli through its internal secretion, which is believed to have an antitoxic
function and therefore is a defence against disease. But it is also involved
in protecting against painful psychical stimuli—fright, mental distress and
violent emotions are given by McCarrison as causes of exophthalmic goitre
which is accompanied by hypersecretion of the thyroid. A temporary enlarge¬
ment of the gland has often been noticed under conditions which produce the
emotion of fear.

This short sketch of the endocrine system gives sufficient data to show
that the * innate conative tendencies ” (McDougall) have a close relationship
with the functioning of the various glands of internal secretion.

Relationship of Emotion to Internal Secretions.

Considered physiologically, emotion may be defined as a psychical experience
which stimulates the whole body to mobilize its latent energy for the purpose

Wilson: The Endocrine Factor in Mental Disease

of augmenting, prolonging and perfecting, or causing inhibition of, normal
instinctive action. Sherrington [18] says: “The pseudo-affective reactions
indicative of resentment and defence are, after ablation of the cerebral cortex,
short-lived, the simulacra of mere flashes of mimetic passion.” “ Reflexes to
which emotion is adjunct are not only prepotent but are imperative, that is,
volition cannot easily suppress them.” The pseudo-affective reflexes of
Sherrington in decerebrate animals are of great interest because they demon¬
strate the process of simple instinctive behaviour divorced artificially from
its emotional component. This process may be described in three stages: (1)
the stimulus; (2) necessary bodily adjustments preparatory to (3) resulting
conduct. The intervention of emotion in this reflex arc may be stimulative
or inhibitive in its action and it may be interpolated either before or after the
first instinctive act has taken place, (a) Emotion may be added before action,
in order, by mobilizing reserve energy, to increase the effect of the response—
for example, a man becomes angry before striking out; (6) be felt after the
first instinctive response has taken place when its function is to augment and
prolong the bodily adjustment in preparation for continued activity. This is
instanced by the sinking feeling which arises after a narrow escape from
danger, a preparation for further eventualities; (c) intervene to inhibit in¬
stinctive action—as when we feel prepared to perform some feat but our
“ heart fails us ” ; or ( d ) may succeed the instinctive act to prevent further
activity as when we have done something of which we feel ashamed.

In discussing the genesis of the emotions, psychologists relate them to the
instinctive tendencies and regard each affective state as one of the means by
which an instinct expresses its influence on behaviour—“ the arrest of an
instinct is that which most frequently excites the emotion connected with it u
(Shand, quoted by Prideaux). Prideaux [19] defines emotion as “a subjective
feeling . . . occasioned by situations which powerfully oppose or facilitate
the aim of any instinctive impulse/* Now, if we correlate the instinctive
tendencies with the glands of internal secretion, we should expect to find a
change in their secretion associated with the emotions, and this change has
actually been demonstrated by Cannon. We know from personal experience
that there is an appreciable latent period between the exciting cause and the
subjective feeling of an emotion, which is quite consistent with the time
required for an alteration in the endocrine balance to affect the central
nervous system. Such an effect will be twofold—a stimulation or inhibition
of bodily processes, and the efflorescence in consciousness of an affective state.

The Endocrine System as the Basis of Feeling-Tone or

PSYCH^STHESIA.

The primal instincts have been associated in the first part of this paper
with the functioning of the glands of internal secretions, and the emotions have
been attributed to changes in these secretions. Affective states, however, are
not essential to everyday behaviour, and there are all gradations of emotion in
quality, intensity and extensity, so we must conclude that they do not arise de
novo , but are simply variations of the normal processes of the bodily economy.
There is, then, a pre-existing feeling-tone upon which the emotion is super¬
imposed, and to which the body normally reverts when the emotional crisis has
passed, and this normal state of feeling, which we may call psychsesthesia,
represents the balance struck by the various primal instincts which govern and
direct all the adaptive processes of the body. From the physiological stand-

Section of Psychiatry

point, psychaesthesia is the crystallization in consciousness of the resultant
effect of all the endocrine secretions working in concert, and, through the
nervous system, it determines and energizes all behaviouristic phenomena in
response to stimuli of external and internal origin. Golla [20] says: “ Our
strongest bond with reality is that of the feelings, which constitute our strongest
defence against the irrational. Mind dissociated from feeling is mind very
much at the mercy of any suggestion.”

Mott [21] considers that “ sexual desire, upon which so many of our mental
activities directly and indirectly depend, is primarily due to the sensitizing
influence of bodily structures on the brain.”

Normal Variations in Psychaesthesia.

The endocrine system, functioning through the blood-stream, must be kept
at a certain level of chemical concentration in order to support life, and there¬
fore the sudden loss of some of its constituent glands, e.g., pituitary or adrenal,
causes death. The potential, however, may vary within certain limits in the
normal individual, and, in fact, it is always in a state of flux, either through
the influence of physical factors such as nutritional disturbance, or
psychical stimuli, such as the hearing of good or bad news or the sight of a
friend.

A more pronounced psych aesthetic change is produced by the taking of
alcohol, after which there is increase of pulse-rate followed by activity of
glandular secretion, causing a feeling of power and well-being, and shortening
the latent period of reflex activity and of behaviour responses in general.
This temporary exaltation of the feeling-tone results in a subsequent re¬
action, with lessened glandular activity, feeling of depression, slowing of
metabolic processes, and conduct of a negativistic resistive type.

To illustrate the effects of a psychical stimulus, I quote from Darwin [22]
the case reported by Crichton-Browne:—

A young man, hearing by telegram that a fortune had been bequeathed him, first
became pale, then exhilarated, and soon in the highest spirits, but flushed and very
restless — later staggering in his gait, uproariously laughing, irritable in temper,
incessantly talking and singing loudly in the public streets—there was no question of
spirituous liquor, though every one thought he was intoxicated. Later there was
vomiting, then he slept heavily, and was well on awakening except that he suffered
from headache, nausea and prostration.

There is no need to dwell on the normal changes in the psychaesthesia, as
these are familiar to all, and instances of alterations of behaviour based on
feeling can be multiplied in the experience of everyone.

The relationship of the instincts and feelings to the endocrine system
and to conduct may now be summarized in the following two
propositions:—

(1) The primitive instincts, based on the endocrine system, are, in
health, harmoniously co-ordinated, each reinforcing or inhibiting the other
for the general welfare of the whole organism.

(2) The resultant of their interaction is represented by the endocrine
balance, and this, acting through the nervous system, determines the affective
tone and at the same time energizes and directs or inhibits the bodily
behaviour in response to stimuli.

28 Wilson: The Endocrine Factor in Mental Disease

Morbid Spates of Feeling as Causes of Mental Symptoms.

A change in the affective tone is one of the outstanding features in a
clinical picture of mental disease, and is well illustrated in states of mania,
melancholia and dementia praecox.

Mania.

The early stages of mania are characterized by a gradual change in the
emotional outlook, a feeling of well-being and increased capacity for active
pursuits. This alteration of feeling is reflected in movement (as Sherrington
says : “Emotion moves us ”)—and there is at the same time a “ liveliness”
among the associated mechanisms in the brain. There is a speeding-up of
thought, speech and action, as observed in the flow of ideas, the rapid articula¬
tion and the waves of emotional expression. Afferent stimuli are also sensitized
so as to cause hyperacuity of all the senses. As the tide of exaltation rises,
activity becomes more manifest and less purposive, conversation is garrulous
and disconnected, instinctive processes are more easily aroused and less con¬
trolled. When the acme of the attack is reached, the slightest stimulus, even
the revival of past impressions in the form of voices or visions, is sufficient
to cause an explosion in instinctive behaviour, shouting, singing, cursing and
unrestrained violence—a state of mental tetanus or psycho-paraesthesia. It
seems as if some subterranean volcano had erupted, pouring out smoke and
flames into the atmosphere without serving any useful purpose, except to
relieve the great pressure within.

As the attack subsides, there is a retrogression of all the symptoms, co¬
incident with a lowering of the feeling-tone and a gradual return to normal,
often followed by a reactionary period of depression.

An example of a more subacute type of exaltation is furnished by an early
case of general paralysis. The patient says he never felt better in his life, he
feels a Samson in strength, and as if he were walking on air. Consequently
all bodily and intellectual processes seem easy to him, and on this groundwork
are built up all his expansive delusions. No criticism can reach him, because
in his elated state he only pities anyone who is not so fortunately placed as
himself. I have had lately under my care a typical case of general paralysis, a
patient with maniacal symptoms and full of grandiose ideas, e.g., “ that he
could drive twenty golf balls 300 yards into a space of 2 ft. square, where they
would be all piled up into a pyramid/* He was treated with injections of
phlogetan, and within a month his mental symptoms had disappeared. During
that time there was a gradual diminuendo of his feeling-tone, pari passu with
the clearing up of his delusions, as instanced by his conversation and the
letters he w r rote. The idea of great muscular power was the last to go, and
disappeared rather suddenly when he collapsed after a walk in the grounds.
The interesting part of this case is that the physical signs, tremor of face,
fibrillary tremor of tongue, and marked hesitation of speech became more pro¬
nounced after the mental symptoms had disappeared. It would seem,
therefore, that the treatment, while it had a minimal effect on the
organic lesion, apparently cured the mental symptoms, which would be
in accordance with the hypothesis that the latter were of glandular origin.

Section of Psychiati'y

Melancholia.

A consideration of the symptoms of melancholia suggests a partial loss of
the capacity of feeling in varying degrees. The opportunity presented itself
of studying closely the case of a very intellectual lady who had suffered for
some years with involutionary melancholia which had a sudden fatal termina¬
tion. In the intervals when she seemed to be less despondent, she conversed
freely on her symptoms and was able to describe very clearly her emotional
tone. She persisted in the statement that there was an entire lack of sensation
which affected the whole body ; that her brain was dead ; that no matter what
she ate she did not taste; she read books and understood them, but they had
no meaning for her. Objectively, there was no loss of skin sensation, proto-
pathic or epicritic, and hearing, sight and smell, were normal. The conclusion
drawn was that there was a real loss of the capacity to feel and therefore
ordinary sensations did not react on the mind in the normal way—this pro¬
duced a feeling of lifelessness or deadness summed up in the expression “ my
brain is dead.” This patient gave a very clear description of the lack of
psychical feeling. She said : “ When I am told that my friends have come to
see me I feel no emotion either pleasurable or otherwise ; I meet them and know
who they are, and that I ought to be happy to see them, yet I can feel nothing,
therefore I would rather not see them.” The lack of feeling-capacity in
depressed states seems to be the origin of the delusions—which are an attempt
by the patients to account for their abnormal affective tone—e.g., “ there is a
devil inside,” “ the taking of food feeds the evil spirit within.” “ I ought to
be in Hell ! ” and 14 1 am going to die ” ; “ food is mixed with filth,” &c. A
great many melancholics seem to approach very near to a correct diagnosis
when they say “ My soul is lost.”

Dementia Praecox.

In the case of dementia praecox there appears to be a lack of emotional
development at the critical stage of puberty, and the patient’s power of
emotional sensation becomes stunted. He cannot understand or interpret the
various stimuli from within or without which appeal to the aesthetic side of
his mind, because he fails to develop the necessary -sensitive plate on which
these sensations impinge. There is a strange aloofness from ordinary life with
a loss of comprehension of soul-stirring events that appeal strongly to his
fellows.

White gives a good description of the emotional deterioration :—

“ The expressions of joy or sorrow, if they occur at all, are shallow and of short
duration. A death, a birth, a marriage, the visit of a long absent relative, are all
apprehended with the same lack of emotional expression. No matter how much
pleasure or pain the event might be supposed to give, or would give in a normal person,
the patient receives it with indifference, without surprise, without an expression of
interest, often in the most matter-of-fact sort of way, as if such things were occurring
hourly.”

Such a lack of the power of feeling may be termed psych-anaesthesia, an
absence of driving force, leading to want of co-ordination in thought and
action, erratic and child-like responses, and all the vagaries of behaviour
characteristic of loss of mind.

30 Wilson: The Endocrine Factor in Mental Disease

This is in accordance with Mott’s [24] conclusions on pathological grounds,
that there is in dementia prsecox an inborn germinal deficiency of productive
energy of the reproductive organs, associated with a progressive deterioration
of psycho-physical energy.

Towards the end of life there may occur such a degeneration of the
emotional apparatus as to constitute an almost complete loss of feeling-
capacity, as illustrated by cases of senile dementia.

There may also be mentioned the temporary paralysis of feeling tone which
occurs during the more active period of life—due to shock, illness or acute mental
disease, viz., the various stuporose states. The characteristic symptom of
stupor appears to be a loss of energizing or emotional capacity which may last
from a few hours to a few months, an acute and often curable form of
anaesthesia of the psyche.

Conclusions.

(1) The gross changes in behaviour, characteristic of mental disease, have
not up to the present been correlated with any definite lesion in the nervous
system, therefore it is justifiable to look elsewhere for the underlying cause of
mental symptoms.

(2) The endocrine glands and their apparently close relationship with the
primitive instincts and emotions offer a field of study which may be prolific in
results to the alienist as well as to the physiologist.

(3) There is evidence that the system of endocrine secretions may be
affected pathologically by both psychical and physical causes.

(4) The endocrine system may prove to be the mechanism through which
mental disease is produced.

REFERENCES.

[1] Cannon, “Bodily Changes in Pain, Hunger, Fear and Rage,” 1920. [2] Golla, “The

Objective Study of Neuroses,” Lancet , 1921, ii, pp. 115, 215, 265, 378. [3] Keith, “Human

Embryology and Morphology,” 1921. [4] Joliffe, “The Psyche and the Vegetative Nervous

System,” New York Med. Journ., April 5, 1922, p. 382. [5] Langdon Brown, “ The Biology of the
Endocrine System,” New York Med. Journ., April 5, 1922, p. 373. (6] Loeb, “The Organism as a
Whole from a Physico-chemical Viewpoint,” Putnam, 1916. [7] Carpenter, “ Mental Physiology,”
1896. f8j Sherrington, “ The Integrative Action of the Nervous System,” 1906. j~9] Darwin,

“ The Expression of the Emotions in Man and Animals,” (Reprint) 1904. [10] McDougaix,

Symposium on “Instinct and Intelligence,” Brit. Journ. Psych., iii, p. 250. [11] Bazf.tt and

Penfield, “ A Study of the Sherrington Decerebrate Animal,” Brain , 1922, xlv, pp. 185-265.
112] Keith, “ The Evolution of the Human Races in the Light of the Hormone Theory,” Bull.
Johns Hopkins Hasp ., May, 1922. [13] MacLeod, “Physiology and Biochemistry in Modern

Medicine,” 1922. [14] Schafer, “ The Endocrine Organs,” 1916. [15] WiRLOCKiand Crowe,

“Note on the Abdominal Chromaffin Body in Dogs,” Johns Hopkins TTniv. Bull., October, 1922,
p. 379. [16] Cannon, “Bodily Changes in Pain,” Ac., 1920. [17] McCarrison, “Thyroid Gland

in Health and Disease,” 1917. [18] Sherrington, “ Integrative Action of Nervous System,” 1906.
[19) PRlDEAl'X, “Expression of Emotion in Cases of Mental Disorder as shown by the Psycho¬
galvanic Reflex, Brit. Journ. Psych., ii, Part I, Med. Sect., October, 1921. [20] Golla.

“Objective Study of Neuroses,” Lancet, August 20, 1921, p. 378. [21] Mott, “Body and Mind—

The Origin of Dualism," Mcnt. Hyy., vi. No. 4, October, 1922. [22] DARWIN, “ The Expression

of the Emotions,” (Reprint) 1901, p. 75. [23] White, “ Outlines of Psychiatry,” 1919 (Washington).
[24] Mott, Second Maudesley Lecture, Journ. Ment. Science, July, 1921.

Section of Psychiatry

DISCUSSION.

Dr. F. Parkes Weber alluded to the mental symptoms sometimes occurring in
endocrine disorders, for instance, in myxoedema and Graves’ disease, and perhaps also
in pituitary gland diseases. Possibly mental symptoms in cases of syphilitic meningo¬
encephalitis might be partly of endocrine origin, due to involvement of the pituitary
gland. He suggested that the well-known euphoria of advanced pulmonary tuberculosis
and of severe septic conditions might be due to the effect of the toxiemic condition on
the endocrine system. (Similarly, it might be suggested that the endocrine system
played a part in puerperal insanity, post-pneumonic mania, &c.)

Dr. H. CRICHTON Miller said that the question of hormonic balance was to his
mind the real crux of psycho-physical interaction. We should never understand the
relation of mind to body, and body to mind, nor yet the physical factors influencing
mental disease—or the mental factors influencing organic disease—imtil we had
recognized the importance of the endocrine balance. He (Dr. Crichton Miller) regarded
the endocrine system as a sort of diaphragm between body and mind, which could be
influenced from either side, and already it was universally accepted that such an inter¬
mediary existed. For instance, no one doubted the emotional result of hypothyroidism ;
nor did anyone question the physical result of fear, as manifested in hyper-adrenia.
If, therefore, we regarded endocrines in the light of an intermediate zone between
mind and body, we would find it easier to understand such relationship as that existing
in the retiology of dementia prtecox, namely, the gonad deficiency, so completely
determined by Sir Frederick Mott, and the psychological failure of the father-complex,
as detected by the analytical researches of Jung and others.

Dr. C. F. Harford said he spoke as one who was especially studying the psychical
aspects of ordinary illness. He had already made various contributions to the psycho¬
logical side of ophthalmology and more recently of tropical diseases; and this had led him
to formulate certain definite conceptions of the relation of the mind to bodily functions.
He (Dr. Harford) regarded the mind, and particularly that part of mind-work which
was unconscious, as the supreme controlling force of all our powers. He believed
that a large part of mind energy was carried out through the intermediation of the
endocrines acting through nervous channels. He thought that too much emphasis was
laid upon the effect of the endocrines upon mind as compared with the effect of mind
upon the endocrines. He believed that psychotherapy might be employed to good
purpose in the early stages of all illnesses associated with endocrine disturbance and
that much good would result.

Dr. PERCY T. Hughes said he questioned the scientific accuracy of regarding the
secretion of the various endocrine glands in terms of excess or diminution only.
Absence or marked diminution of the thyroid secretion was undoubtedly the cause of
myxoedema, but was it equally evident that Graves* disease with all its mental
accompaniments was due solely to excessive output of normal thyroid secretion ?
Dr. Hughes suggested that the symptoms of Graves’.disease were due not merely to
excessive thyroid secretion but to a toxaemia caused by the pathological changes in the
thyroid owing to which its secretion was so much altered as to become definitely toxic.
He would apply the same suggestion to pituitary conditions resulting in acromegaly.
Again, having regard to the pronounced pathological changes in the testicle and ovary
in dementia preecox, as described by Sir Frederick Mott, might not the mental symptoms
in this disease be due, or partly due, to a toxaemia arising directly from the patho¬
logical changes in these glands *?

Lieutenant-Colonel Haynes said he would draw attention to the fact that during
the evening nothing had been said regarding the restoration of the endocrine balance.
We had no evidence that the action of endocrine extracts introduced by the mouth, or
even subcutaneously, was similar to that of the living gland. He suggested that work
to ascertain the value of such extracts and the most useful method of administering
them would prove of the utmost value.

32 Wilson : The Endocrine Factor in Mental Disease

Dr. Hubert Bond (President) said that Dr. Leitch Wilson had collected and
summarized much important work that had been done and published upon the subject,
and several valuable suggestions had helped to clarify points of difficulty. He
(the President) felt encouraged and hopeful for the future when he saw someone whose
work was mainly clinical, thus studying and thinking out his cases in terms of labora¬
tory results; and a paper such as this added strength to his (the President’s) reiterated
contention that sound clinical work could not be carried out in any mental hospital
without the aid of the laboratory.

Section of pa$cblatn>.

President—Dr. C. Hubert Bond, C.B.E.

Genius and Insanity.

By Hubert J. Norman, M.B.

For many centuries it has been recognized that there is a definite correla¬
tion between genius and insanity. Aristotle (“ Problemata noted ”) the
frequency with which “ melancholy ” occurred in statesmen, philosophers, poets
and others who occupied a prominent position in the community. Seneca,
basing his statement on Aristotle’s observation, said that “ Nullum magnum
ingenium sine mixturae dementiae fuit” (De Tranquillitate Animi). It was
from Seneca that Dryden apparently derived this idea, and he embodied it in his
Great wits are sure to madness near allied ” : the immediate application
being to Lord Shaftesbury in “ Absalom and Achitophel,” in which he is
described as :—

u A fiery soul, which, working out its way.

Fretted the pigmy-body to decay.

And o'er-inform’d the tenement of clay.”

This is an admirable description of what has been sadly and frequently
exemplified in the life-histories of men of genius.

It was, however, not until a later time that the suggestion was worked out
in a more definite way, and an endeavour made to deal with it as far as
possible from the physiological aspect. L6lut, in 1837, published his book,
44 Du D£mon de Socrate,” in which he showed conclusively that Socrates
suffered from hallucinations. The subject was followed up by other French
writers, notably by Morel and by Moreau (de Tours). Moreau indeed went so
far as to say that genius was a n&vrose , or nervous disorder, his contention
being that “ originality of thought and quickness or preponderance of the
intellectual faculties were organically much the same thing as madness.”
This theory w f as supported by Lombroso in his 44 Genius and Madness,” and it
is upon Lombroso that most of the odium has fallen for the promulgation of an
opinion which, as has often been pointed out, is really a very ancient one. It
may be said in passing, however, that Lombroso’s views on this matter and his
work in criminology deserve respectful consideration rather than the petulant
detraction to which they have so often been subjected. It was to Lombroso
that Max Nordau dedicated his vigorous and entertaining volume, 44 Degenera¬
tion,” in which he subjected those whom he considered decadents to the most
mordant criticism.

No sketch of the progress of this conception would be complete without

Je— l J s 1 : March 13, 1923.

Norman: Genius and Insanity

a reference to one of the most able books written on the subject, namely,
Nisbet's “ The Insanity of Genius ” (1891). 1 The work of one who was not a
trained psychologist or physiologist, it is remarkable for the manner in which
both psychology and physiology are invoked to show that great intellectual
power is not found, as a rule, “ without some disturbance of the healthy
equilibrium of the brain and nervous system.” This corollary seems irre¬
fragable : biographies of eminent people reveal the fact that nervous instability
is an almost invariable concomitant, while actual insanity occurs with extra¬
ordinary frequency.

Problems in psychology—and even in psychiatry—have been too frequently
discussed from an abstract point of view. In spite of much that is still said to
the contrary, the only real advance has been made from the physical and
biological approach. Psychology based upon abstractions which do not take
into account the dependence of mental action upon nervous processes must
continue to be unfruitful—allowance being made, of course, for the plentiful
crop of Dead Sea fruit always to be found in the metaphysical garden ! Consider
for a moment the weary speculations about dualism and psycho-physical
parallelism. In either case we are asked to presuppose a discarnate something
which may impinge at will on some part of the brain or body. This kind of
supposition has presented us with the fatuities of spiritualism and dowered us
with seven thousand devils ! Why not in the same way conceive a dualism
between Respiration (with a capital R) and lungs, or between Digestion and
stomach ? It is amazing to have a distinguished scientist saying at the present

time that: “ Biology is distinct from psychology. Biology must be

regarded as an independent science. 8 While another remarks that: “ The gap
between the physiological and the psychological is unbridgeable.” Apparently
when a process becomes so highly refined as to elude our methods of investiga¬
tion for the time being, all we have to do is to make an arbitrary division, give
the later part a new name, then say that it has no connexion with its com¬
mencement. “ When the human mind could advance no further,” said
Swedenborg, " it admired its last result and accordingly took it for God.” 8

It may be taken for granted—here, at any rate—that mental processes
are a subject for the study of the physiologist as well as for the psychologist,
and it does not matter whether these processes are normal or morbid.
Those of the genius differ only in degree and not in kind from those of
others. Genius does not depend upon some mysterious inspiration or
divine influx, but is the result of a difference of a dynamic kind, of energy
working in a structure which differs in the quality and quantity of its
nervous arrangements in one individual as compared with another. What
“ energy ” is remains a question for the biologist and the physicist. “ Genius
to my mind,” said Huxley, “ means innate capacity of any kind above the
average mental level. From a biological point of view I should say a ‘ genius *
among men stands in the same position as a ‘ sport ’ among animals and
plants, and is a product of that variability which is the postulate of selection
both natural and artificial. . . . On the general ground that a strong and
therefore distinct abnormal variety is, ipso facto , not likely to be so well in
harmony with existing conditions as the normal standard, which has been

1 A new edition, with an introduction by Dr. Bernard Hollander, was published in 1912
(Lond., Stanley Paul and Co.).

,J J. S. Haldane, “ The Fundamental Conceptions of Biology,” Brit. Med. Journ ., March 3,
1923, p. 363.

* Swedenborg, The Infinite and tin* Final (,'auar of Creation,” London, 1908, p. 81.

Section of Psychiatry

brought to be what it is largely by the operation of those conditions, I should
think it probable that a large proportion of 4 genius sports * are likely to come
to grief, physically and socially/’ 1 Obviously Huxley does not use the word
“ innate ” in the sense in which it was employed by some philosophical writers,
but rather as implying the inborn difference of potential which enables one
person to develop more rapidly or more fully than another. Hugh Elliot 2
suggests that: “ The genius is a man in whom mental energy is distributed
unevenly—great strength in alliance with weakness ” ; and he points out that
there must be intellectual capacity as well as emotional abnormality.
“ Intellect alone can accomplish nothing; it is the emotional force pushing
from behind that is the prime agency.”

There does not seem to be the necessity in such individuals for that “ trans¬
cendent capacity of taking trouble,” which Carlyle mentions as the attribute of
genius. The mind of the genius is of such a kind that it readily absorbs
information—that is, the cerebral reactions are rapid, canalization is easy, and
there is also great facility for association. Instead of the process being laborious
and slow, it is rather unduly quick; and conscious effort is necessitated, as a
rule, by the relatively vast extent of mental work attempted. Or again a
feeling of strain may result in one who, accustomed to do much with ease,
finds himself temporarily unable to accomplish even his usual amount of
work.

In such a brain there is a relatively large proportion of cellular elements in
an unstable condition (according to Hughlings Jackson’s dictum that the latest
acquirements in the course of evolution are the most complex and least
organized). Further, as any organization is likely to respond to stimuli and
endeavour to fulfil its function, the strain upon the more complicated mechanism
will be greater, and the tendency to breakdown will, therefore, be more
evident. This tendency which we should on a priori grounds expect, as Huxley
points out, to be present, is undoubtedly demonstrated in the life-histories of
those of pre-eminent intellectual capacity. It does not follow that in their case,
any more than in that of ordinary people, the breakdown is a permanent one.
The stoppage of mental work, which inevitably results in so many instances,
may be part of Nature’s scheme to give rest to overworked tissues, just as
sleep has been arranged in order to “ knit up the ravell’d sleave of care ” and
to act as a " balm of hurt minds.” Thus we may find that there are phases of
intense mental energy, comparable to the waking stage, which are followed by
periods of sluggish brain action when no productive work can be done. This
is strikingly exemplified in the earlier part of the life of Nietzsche before a
complete failure of his mental energies took place. Until we know more of
the etiology of the manic-depressive conditions it is not possible to speak
dogmatically about the matter, but it certainly seems as if the normal flux and
reflux of energy are merely accentuated in these cases. It is obvious that,
taking into account the variations of the phases in one individual as compared
with those in another, there are degrees of intensity such as would allow of
cases being graded insensibly from ordinary fluctuations of cheerfulness and
depression onwards to those instances in which acute mania and acute
melancholia alternate. In the milder cases there seems to be no reason why
the onset of the excitement—or even the whole of that phase—should not be
accompanied by an increase in productiveness, especially in so far as work

i Siec Nisbet, “ The Insanity of Genius,” 2nd ed., 1893, p. xxi. (Cf. also “TheLife and Letters
of T. II. Huxley,” i, p. 346.)

5 Hugh Elliot, “ Human Character” (Loud., 1922), p. 196.

IS orman : Genius and Insanity

of an imaginative character is concerned. What seems to be necessary is a
decrease of inhibition or an increase of stimulation—or both at the same time.
The great importance of the products of the ductless glands must be recognized
in speeding up the action of the nervous system. 1 Then there are substances
like alcohol, opium, hashish, and heroin. It seems to be indubitable that such
writers as Coleridge, De Quincey, Edgar Allan Poe, and Verlaine, to mention
no others, were considerably influenced by drugs: though it should always
be remembered that the drug addiction may be secondary to the nervous
instability. There are, too, other toxic factors. The fluctuations of temperature
in tuberculosis, pointing as they do to metabolic changes and to morbid
stimulation have their influence, and they cannot be left out of the account,
in considering the lives of, for example, Keats, R. L. Stevenson, and Aubrey
Beardsley. The flight of ideas in mania is obviously due to such a degree of
lack of inhibition that associations take place so rapidly as to be apparently
incoherent. It is not difficult, however, to trace the close relationship between
this condition and that which exists in the mind of the writer or of the artist
at certain periods. In both we find the fantastic elements which are
symptomatic of the “fine frenzy.” Careful editing has deprived the world
of much valuable evidence in this respect: and though this may be no great
loss from the literary or the artistic point of view it is decidedly so in so far as
psychiatry is concerned. When dealing with a record of abnormal mental
phases the biographer is only too apt to suffer from suppressio vert. If accurate
records could be obtained it would be interesting to ascertain the exact
Association of the various phases of mental disorder with intellectual work.
If Napoleon, Julius Caesar, and Mahomet really suffered, as has been stated,
from epilepsy, their superabundant energy may sometimes have shown itself in
the form of fits, while at others it would have an outlet in increased cerebration ;
or there may have been a number of attacks of masked epilepsy which would
not have been recorded as epileptic seizures. Paranoid and delusional insanity
may generally co-exist with a high degree of intellect, as the lives of Swedenborg
and of Rousseau demonstrate. Sexual abnormalities appear to be a not unusual
concomitant of superior intellectual capacity. It seems clear, however, that
the more pronounced the insanity the less is the capability for producing what
may be really regarded as the work of a genius-mind. But here the difficulty
arises of deciding what is meant by a product of genius. What is described
by devotees as such is looked upon by less prejudiced observers as fantastic,
•eccentric, or morbidly abnormal. It is difficult to arrive at a decision in
general principles. Each case must be considered on its merits ; for what may¬
be the product of insanity in one instance may be in others imitation by the
44 sedulous apes ” who, noticing that the public like that kind of thing, see
that they get it. Even where we are dealing with true genius there are apt
to be, as might be expected, great inequalities in the value of their work.
To say that a person may be the “ greatest, wisest/* and at the same time, the
4< meanest of mankind*’ is perhaps rather an example of poetic license: but it
•conveys tersely the condition of unequal cerebral development so characteristic
of genius. It helps to elucidate also the conjunction of credulousness in one
direction with scepticism in another, of charity with bigotry, and of general
benevolence with private cruelty. “ Vir teres atque rotundus " mentally and
physically, is a pious aspiration rather than an actuality.

i The well-known works of Cannon and of Crile may be mentioned. The subject is dealt with
ut length in a most interesting way by Dr. Louis Berman in “ The Glands regulating Personality M
New York, 1921).

Section of Psychiatry

Genius, then, is a product of a brain in a state of unstable equilibrium.
The possessor being more or less of a “ sport,” is not, therefore, one of the
“ fittest,” that is, he is not one of the best adapted to environment. In many
cases this results in his being eliminated by the more stable members of the
herd, in the same way as the weakly children were exposed to death by’
the Spartans. Or, as he lives for the most part in a vicious circle because
of the tendency to overwork or to react unduly to stimuli, the threshold of
sensibility being still further lowered in the process, the chances of a temporary
or a permanent breakdown are much greater than in the less impressionable,
less reactive individual.

Genius and insanity are both results of nervous instability. Insanity does
not cause genius but for the most part is inimical to intellectual effort: though,
because cerebral deterioration is often a slow and insidious process, the mental
defect may not be obvious for a considerable time after the onset of the
condition which will eventually lead to definite insanity. It may be said with
more truth that genius is much more likely to lead to insanity: insanity being
the price which nature exacts in this instance for valuable but delicately-
constructed gifts. The genius, because of his organization, is an intractable
person who is apt to place an undue strain upon his resources and who has to
pay the penalty for doing so. When it is realized that his mental work—
like that of ordinary people—is dependent upon the functioning of physical
structures, more care may be taken to conserve the nervous mechanism.
But that is a counsel of perfection which is disregarded by the genius, and is
little likely to be taken by the average man !

DISCUSSION.

Dr. STODDART doubted the accuracy of Dr. Norman’s premises. He had had the
good fortune of personally knowing two geniuses, viz.: Dr. Hughlings Jackson and
Professor Freud, and he had never met two saner men. As to the acknowledged
geniuses of all ages, Hippocrates, Galen, Aristotle, Copernicus, Galileo, Shakespeare,
Goethe, Hegel, Newton, Darwin and Dickens for example, he (Dr. Stoddart) was not
aware that there was any evidence that these great men had been insane, although
admittedly some had had their peculiarities. Dr. Stoddart also combated Dr. Norman’s
materialistic conception of mental phenomena. Nobody had ever doubted the intimate
connexion between mind and brain, but modem psychological investigation of the
neuroses and psychoses had afforded a satisfactory explanation of them, such as had
never before been achieved.

Dr. W. Wallace said that he had been interested in this subject for many years.
I>r. Norman had mentioned Nisbet’s “Insanity of Genius,” but Dr. Wallace would like
to know if Dr. Norman had read it from cover to cover. It was a book that had done
much harm, and its conclusions and vast assumptions were ludicrous and mischievous.
So glaring was Nisbet’s complete lack of knowledge that one wondered why he had not
made out a case of insanity from housemaid’s knee. Milton was said to have lost his
sight from congenital causes ; a new view to take of glaucoma . 1 A great deal had been
made of Beethoven’s so-called eccentricities, but so fully conscious was the composer
that his conduct, due to his deafness, might be misunderstood, that he pledged his
doctor to publish a report on his “ case” when he was dead. He did not die insane,
although the post-mortem appearances would have justified this conclusion, in the
absence of any clinical history or knowledge of the man. The speaker showed a
photograph of Beethoven’s skull, with great thickening of the right parietal bone. The

1 See W. Wallace, “The Musical Facility,” Loud., 1914, in which Nisbet's views are discussed
at length.

Norman: Genius and Insanity

y>ost-mortem report stated that the auditory nerves, especially that on the right side,
were atrophied, there was ulceration of the larynx and the nodulated liver was shrunk to
half the normal size. Lauder Brunton gave the opinion that these lesions were
syphilitic in origin . 1

Dr. Wallace said that throughout his life he had associated intimately with creative
artists, sculptors, painters and musical composers, not all geniuses perhaps, but men
who had secured national, and in some cases world-wide recognition, but he had not met
with a case of insanity among them, either from his own observ ation or by hearsay.

i This view in not accepted by T>r. Georges Cauuyt. See ik La Surdite de Beethoven ’* in AunaUs
flr,n Maladies dc VUrcille for January. 192:1. Apparently the writer had not seen the photograph
of the skull or the post-mortem report .

Section of popcbiatrs.

President—Dr. C. Hubert Bond, C.B.E.

Pathological Laughing and Crying . 1

By S. A. Kinnier Wilson, M.D.

The problem presented by certain cases of abnormal emotional expression,
in the guise either of exaggerated or uncontrollable laughing or crying, or
conversely of paralysis (at least in part) of the same mechanism, has not
attracted much attention in recent years, nor has much advance been made on
the views advocated by Nothnagel and by Brissaud, some thirty years ago or
more. The time has come when the whole question is ripe for reconsideration.

Reference is here made solely to cases of organic nervous disease in which,
as a sequel to, and consequence of, a recognizable cerebral lesion or lesions,
“ attacks ” of involuntary, irresistible laughing or crying, or both, come
into the foreground of the clinical picture. Cases are also examined in
which there is conservation of voluntary facial movement with paresis or
paralysis of the same musculature for the involuntary movements of facial
expression.

Among the organic affections apt to be associated with these phenomena
are double hemiplegia, pseudobulbar paralysis, disseminated sclerosis, &c.; the
exact nature of the morbid affection is of less importance than its site. They
may occasionally occur in unilateral cases.

A considerable number of personal cases are analysed to show the nature
and the varieties of the syndromes under investigation. Attention may be
directed to some particularly valuable observations dating back nearly a
century, recorded by Sir Charles Bell and by Stromeyer. The association of
involuntary respiration with involuntary facial movement is such that both
of these may be unilaterally paralysed if the lesion is appropriately situated.

The natural question that arises is whether the emotional outbursts
correspond to or reflect the mental state of the individual concerned at the
moment of their expression. It can be shown that in not a few instances they
do not. Patients may be forced to express a particular emotion in opposition
to their real feelings. The bearing of the facts on the James-Lange hypothesis
is obvious. It is clear that the bodily reverberation, as James calls it, is not
per se the emotion, and the theory must be materially modified to bring it into
line with the observations reported.

The mechanism of the emotional expression is one in which, on the somatic
side, facial and respiratory musculatures are implicated.

i The paper will appear in full in a forthcoming number of the Journal of Neurology and
Psychopathology.

* [February 13, 1923,

Wilson: Pathological Laughing and Crying

Clinical study reveals the existence of three types of interrelated motor
disorder in this connexion: (1) The face may be unilaterally paralysed for
voluntary movement but not for emotional expression ; (2) it may be bi¬
laterally thus paralysed; (3) voluntary control may be perfect, while emotional
facial expression is unilaterally (or it may be bilaterally) affected. Considera¬
tion has led to the development of the idea that there are separate and distinct
paths for emotional and for volitional facial movement. Examination of the
hypotheses of Nothnagel and of Brissaud shows that they do not entirely
accord with all the known facts.

There is a voluntary control over the facio-respiratory mechanism, and there
is an involuntary control. The voluntary control is exercised by way of the
cortico-ponto-medullary path ; for the involuntary control we have two distinct
paths, the existence of which may be demonstrated by physiological experiment
—a non-pyramidal, arresting path and an accelerating path. These have been
traced from the cortex, through the regio subthalamica , to the appropriate
nuclei. Involuntary laughing and crying are allowed by lesions of the
voluntary path ; emotional paralysis is produced by lesions of the other.
The two clinical conditions may occur in association. The thalamus cannot
be more than a link in the chain, of which the cortex must form a part.

PROCEEDINGS

OP THE

ROYAL SOCIETY OF MEDICINE

EDITED BY

Sir JOHN Y. W. MacALISTER

UNDER THE DIRECTION OK

THE EDITORIAL COMMITTEE

VOLUME THE SIXTEENTH

SESSION 1922-23

SECTION OF SURGERY

[Including the Proceediruju of the SUB-SECT ION OF PROCTOLOGY]

LONDON

LONGMANS. GREEN & CO., PATERNOSTER ROW

1923

Section of Suraen>.

OFFICERS FOR THE SESSION 192*2-23.

President —

James Berry, F.R.C.S.

Immediate Past President —

Raymond Johnson, O.B.E., F.R.C.S.

Vice-Presidents —

Cyril A. R. Nitch, M.S. Herbert J. Paterson, C.H.E., M.C,

H. S. Clogo, M.S.

Hon. Secretaries —

V. Zachary Cope, F.R.C.S. Philip Turner, M.S.

Other Members of Council —

H. W. Carson, F.R.C.S. h. B. Rawling, F.R.C.S

C. H. S. Frankau, C.B.E., D.S.O., F.R.C.S. H. S. Soottar, C.B E

T. P. Lego. C.M.G., M.S. Gordon Taylor, O.B.F.,

W. Ernest Milbs, F.R.C.S. G. Grey Turnbr, M.S.

Garnett Wright, F.R.C.S.

Representative on Library Committee
F. F. Bcrghard, C.B., M.S.

Representative on Editorial Committee—

Philip Turner, M.S.

Sub-Section of proctoloQS.

President —

Sir Charles Ryall, C.B.E., F.R.C.S.
f Died September, 1922. Sir Charters Symonds, K.B.E., M.S., electe iesl

October, 1922.]

Vice-Presidents —

Sir Charles Gordon-Watson, K.B.E., C.M.G., F.R.C.S.

J. P. Lockhart-Mummery, F.R.C.S.

W. Ernest Miles, F.R.C.S.

Hon. Secretaries — ^

Pkrcival P. Cole, F.R.C.S. C. W. Kowntrke, F.B.C- •

Other Members of Council — y j;

H. Graeme Anderson, M.B.E., F.R.C.S. Sir A broth not Bane, Bart.. - ^
James Berry, F.R.C.S. L. E. C. Nokbury, C.B

F. Swinford Edwards, F.R.C.S. Sir John Fynn Th

\V. B. Gabriel, M.B. C.M.G., F.R.C.b.

C. H. Shornky Webb, F.R.C.S.

SECTION OF SURGERY.

CONTENTS.

November i, 1922.

James Berry. F.R.C.S. (President). pace

The Progress of Surgery and the Rise and Fall of Surgical Operations ... 1

January 3, 1923.

W. Sampson Handley, M.S., F.R.C.S.

On Subcapsular Pyelotomy, with Remarks on the Origin and Treatment

of Renal Calculi ... ... ... ... ... ... 2

February 7, 1923.

G. Grey Turner, M.S. (Newcastle-upon-Tyne).

A Case in which an Adenoma weighing 2 lb. 8 oz. was successfully
removed from the Liver: with Remarks on the Subject of Partial
Hepatectomy ... ... ... ... ... ... 48

Garnett Wright, F.R.C.S. (Manchester).

Primary Carcinoma of the Liver excised by Operation ... ... 56

Claude Frankau, C.B.E., D.S.O., F.R.C.S.

A Case of Resection of the Liver for Malignant Disease spreading from

the Gall-bladder ... ... ... ... ... ... 59

Philip Turner, M.S., F.R.C.S.

Case of Excision of an Adenoma of the Liver which had ruptured

spontaneously, causing Internal Haemorrhage ... ... ... 60

Frank Kidd, M.Ch.Cantab., F.R.C.S.Eng.

Case of Primary Tumour of the Liver removed by Operation ... ... 61

Discussion (pp. 62-64) : Mr. A. J. Walton, Mr. Cyril Xitch.

May 2, 1923.

J. P. Lockhart-Mummkry, F.R.C.S.

The Technique of Resection and Anastomosis of the Colon for Tumour ... 69

Charles A. Pannbtt, F.R.C.S.

The Technique of Axial Anastomosis of the Aliment< ntary Canal ... 81

Contents

March 7, 1923.

Sir G. Lknthal Cukatle, K.C.B., E.R.C.S. parr

The Sites of Origin and Methods of Growth of Fibro-adenomata of the

the Breast ... ... ... ... ... ... ... s. r >

Ernest II. Shaw, M.R.C.P.

Demonstration on the Immediate Microscopic Diagnosis of Tumours at

the Time of Operation ... ... ... ... ... #5

Cecil Rowntrke, F.R.C.S

Two Cases of Sarcoma of the Small Intestine ... ... ... sr»

Frank Kidd, M.Ch.. F.R.C.S.

Case of Large Spindle-celled Sarcoma arising in the Mesentery of a Co)

of Ileum successfully removed at Operation ... ... Nfi

June 6, 1923.

R. H. Anglin Whitklockk, M.D., F.R.C.S.

The Treatment of Fractures of the Patella ... ... ... . 1R

H. P. Wins bury White, F.R.C.S.Fmg.

The Closure of the Suprapubic Urinary Fistula following Suprapubic

Prostatectomy ; Observations on Sixty-eight Cases .. ... H9

SU B-SECTION OF PROCTOLOGY.

November 8, 1922.

Sir Charters Symonds, K.B.E., C.B., M.S. (President\

Gonorrhoeal Stricture of the Rectum

February 14, 1923.

J. P. Lockh art-Mummery, F.R.C.S.

A New Method of treating Ischio-rectal and other Abscesses ...

Lionel E. C. Norbury, F.R.C.S.

Case which was clinically one of Inoperable Carcinoma of the Rectum
treated by Colostomy and Subequent Injections of Cuprase-Collosul
Selenium and Collosal Cuprum for over Two Years, with Disappear¬
ance of the Growth

Shown by Percival Cole, F.R.C.S.

A Specimen of Colon, showing Multiple Perforations resulting from
Dysentery

April ii, 1923.

Herbert H. Brown. O.B.E., M.D.

Patient upon whom an Operation was performed in June, 19*20, for
Cancer of the Rectum, by the Abdoulino-anal Method

J. 1\ L«»ckhart-Mummkhy, F.R.C.S.

Case of Early Tabes Dorsalis

Conte n ts

May 9, 1923.

DISCUSSION ON ULCERATIVE COLITIS.

Sir Humphry Rolleston, K.C.B. (p. 91), Sir Thomas Hokdkk (p. 96), Mr. J. P.
Lockhart-Mummkry (p. 97), Dr. W. E. Carnegie Dickson (p. 100), Professor
Leonard S. Dudgeon (p. 104), Dr. A. F. Hurst (p. 106). Sir Charles
(tordon-Watson (p. 109), Mr. Douglas Drew (p. 109).

The Society does not hold itself in any wa\ responsible for the statements made
or the views put forward in the various papers.

London :

John Bale, Sons and Danielsson, Ltd.,

Oxford House,

83-91, Great Titchfield Street, Oxford Street, W. 1.

Section of Surgery.

President—Mr. Jambs Berry, F.R.C.S.

The Progress of Surgery and the Rise and Fall of Surgical

Operations.

PRESIDENT’S ADDRESS.

By James Berry, F.R.C.S.

My first duty, and a very pleasant one, is to thank the Section for the
honour it has conferred upon me by appointing me your President for the
ensuing year. It is an honour which I appreciate very highly, and although I
think you might easily have found a better president, I will only say that I
will do my best to justify the confidence which you have so kindly placed in
me. May the ensuing season be productive of much good work, may our
discussions continue to be carried on with fearless outspokenness, with good
temper and with liveliness, as they have been in the past.

My second duty is a more onerous one, and the responsibility of it weighs
heavily upon me. It is to inflict upon you a Presidential Address. Any form
of public address is always a sore trial to me, but I am encouraged by the
thought that I have before me a kindly and sympathetic audience.

During my surgical life it has fallen to my lot to witness the most
wonderful progress that I suppose surgery has ever made in so short a time.

When a student I just saw the termination of the old pre-antiseptic days.
I was able to watch the gradual development, first, of antiseptic surgery in all
its varying phases, of operating in a fog of carbolic spray, of treating clean
operation wounds with poisonous and irritant lotions—the washing out of the
peritoneal cavity with 1 in 20 carbolic acid lotion and with solutions of per-
chloride of mercury and other abominations so distasteful and so harmful to
the living peritoneum.

Tuberculous joints were for many years treated by most surgeons by
extensive and mutilating excisions, performed, even in early cases, with the
usually mistaken idea that all the tubercle could thereby be eradicated.
Indeed so far was this practice carried that on one occasion I saw a perfectly
healthy head of the femur excised from an unfortunate child who was
supposed to have early tuberculous disease of the hip.

Then came the gradual development of aseptic surgery under which so
many of the greatest advances of modern operative surgery have been made.
Even aseptic surgery, as opposed to antiseptic, has at times been carried too
far, as was found during the early stages of the war when some of the younger

Ja—S 1 [.November 1, 1922.

Berry: The Progress of Surgery

surgeons, who had been brought up only in the strict aseptic school,
endeavoured to apply asepsis (I use the term in its narrow sense) to the treat¬
ment of foul and gangrenous wounds which were more suitable for treatment
by antiseptics.

In the eighties the operative surgery of the skull and brain was little more
than the trephining or elevation of compound depressed fractures and the
occasional, and usually fatal, opening of a cerebral abscess.

t)eep dissecting operations at the root of the neck were comparatively
rarely performed, on account of the extreme danger of opening up the cellular
tissue of the neck in days when antiseptics were in their infancy, and asepsis
in its modem form unknown. Thoracic surgery was mainly the opening of
empyemata, with an occasional adventure into a suppurating pericardium and
now and then some kind of operation upon the chest wall for old empyema.
Abdominal surgery was in its infancy. The fear—and the fully justifiable
fear—that most surgeons had of opening the peritoneal cavity, seems strange
to us, who now, thanks to improvements in surgical technique, think nothing
of so doing. I have seen a man die of acute peritonitis after a trivial operation
upon the abdominal wall which involved a small opening of the peritoneal
cavity, by one of the most noted surgeons of the day. I remember witnessing
what must have been one of the very first operations for the removal of a
renal calculus, an operation which we have all been doing for many years with
ease and safety, and in most cases with complete success.

Hysterectomy in those early days was being done with a wire 6craseur
and extraperitoneal treatment of the stump. Cancer of the tongue was usually
removed by means of the barbarous chain or whipcord 6craseur. A curious
instance of the modern revival, in an improved form, of an ancient operation,
is the quite recent, and now somewhat fashionable, operation of removal of
the tongue by diathermy. One of the first operations I ever saw for removal
of the tongue for cancer (I think it was the very first) was done with a galvanic
cautery by the late Mr. Callender. It is well to remember that the reasons
which led then to the rejection of the cautery—namely, the danger of sepsis
and secondary haemorrhage, still exist. If I may be permitted to express an
individual opinion it is that a properly executed operation for removal of the
tongue from the outside, the method that I nearly always myself perform for
bad cases of cancer, gives better results than diathermy, although I know that
many excellent and experienced surgeons hold an entirely opposite view.

Perineal lithotomy was a common and favourite operation in my early
days of surgery, although it quickly went out of fashion, being superseded by
the much more easy, and, on the whole, more satisfactory, suprapubic operation.
The old-fashioned lumbar colotomy was being replaced by the more satisfactory
inguinal operation. When this later operation first came in accidents and
complications connected with it were not uncommon. Such were prolapse of
the bowel, from not taking sufficient care to draw the sigmoid well down before
fixing it, dropping back of the sigmoid into the peritoneal cavity because the
mesentery had not been firmly fixed to the abdominal wall, the escape of a few
feet of small intestine into the bed a few days afterwards because the wound
in the abdominal wall had been made too long or incompletely closed. All
these accidents I have seen more than once and they still sometimes occur in
cases in which colotomy is done for obstruction with distension.

At the present time colotomy for intestinal obstruction is a little out of
favour and there is a tendency to replace it by caecotomy. It is perhaps not
sufficiently recognized that the opening of the caecum under conditions of great

Section of Surgery

distension is by no means always a simple or easy operation and many a caecum
has been burst in the process. It is easy enough when the abdomen and bowel
are not distended.

It is a truism to say that most of the progress that has been made in
surgery is due to the application first oi antiseptic and later of aseptic
principles to the treatment of operation wounds. I well remember the old
days when I used to see surgeons of eminence operating in old frock coats,
the discards of the consulting room, splashed and stained with blood and pus,
the result of many previous operations. The more dirty the coat, the greater
seemed to be the pride of the surgeon who wore it. He did not always even
trouble to wash his hands before undertaking an operation. To those
accustomed only to the white gowns, masks, rubber gloves and all the
necessary paraphernalia of the modern operating theatre, such a condition
of affairs must seem almost incredible. I have seen surgeons in the olden days
undertake major operations with scarcely a pretence of cleanliness. I have
seen a hospital surgeon stop in the middle of an operation to scratch his head
and think, put his hand in his pocket, draw out and put on his spectacles, and
then at once proceed with his operation. I have seen another bite a ligature
with his teeth when the scissors were not handy.

Many of the highly technical operations of the present day depend for their
success not merely on skilful technique and strict asepsis. These can be learnt
more or less thoroughly from books. But many of them demand also a
thorough knowledge of the pathological conditions likely to be met with in the
actual performance of them. This knowledge is more difficult to acquire and
the lack of it may easily lead by an error of judgment to a fatal disaster.
Take the case of cholecystectomy, a very successful and satisfactory operation
in the hands of skilled surgeons. But in my opinion it often requires much
judgment to know when it should be performed and when it is better to
substitute for it the simpler and easier operation of cholecystotomy.

“ I can teach my assistants how to operate in six months, but to teach
them when to operate takes twenty or thirty years ”—is a recent saying
attributed to an eminent French surgeon.

We are all of us, I think, a little too apt to be impressed by the brilliant
results that may have been obtained by some star performer after years of
study and experience. A cholecystectomy that in a particular case may be
quite the right operation for a Moynihan or a Mayo may be quite the wrong
operation for Mr. A. or Mr. B. to perform, as he may find to his cost and to
that of his patient. An extensive operation for a tumour of the brain may
be a brilliant success in the hands of a Harvey Cushing or a Sargent, but a
terrible disaster if undertaken by anyone who has not had special training in
this line of practice. A slight error in the placing of the suture in a gastro¬
enterostomy, the careless application of a single ligature in a thyroidectomy,
the placing of a clamp in the wrong place in a cholecystectomy, may each of
them easily lead to the death of the patient and have often done so.

We sometimes hear of the mortality of such and such an operation. There
is no such thing. The mortality depends upon the condition for which it is
done, upon who does it, and how and when it is done. I am reminded of the
old story, doubtless an invention, of the man who was about to undertake
a very serious and dangerous operation and he assured the patient that it
would be entirely successful. When pressed for the reason of his great
confidence, he said, “ Well, the mortality of this operation is 95 per cent.
I have already done it nineteen times and all the patients have died. This is
the twentieth and he is bound to recover.”

Berry: The Progress of Surgery

In these days of greatly increased knowledge in diagnosis, in pathology and
technique, it has become possible, with the help of asepsis, to penetrate with
impunity to regions of the body which formerly no surgeon would have dared
to touch. Extensive operations upon the bladder, the intestine, the stomach,
the biliary passages, the lungs, frhe thyroid and the brain, to mention only
a few, are among the wonders of modern surgery. It is quite unnecessary,
however, for me to embark on any detailed description or eulogy of these
triumphs of surgery, which are sufficiently well known to all of us.

At one period of my surgical career (1892-98) I had the good fortune to be
surgical registrar to one of the largest London hospitals for more than five
years. During that period it was one of my numerous duties and privileges
to make all the surgical post-mortem examinations, about one thousand in
number. During this same period, I was also full surgeon to another large
metropolitan hospital with a medical school.

The experience gained in the one department was invaluable to me in the
practice of the other, and especially in the complicated and difficult field
of abdominal surgery. A surgical registrar doing a post-mortem has the
opportunity of imagining that he is operating on the living, and of learning
what are the conditions and the difficulties that he may expect to find when he
comes to operate on his own patients. I venture to think that a young surgeon
who aspires to make a name for himself in surgery can have no better training
than is given to him by holding the post of surgical registrar, if that post
involves, as it should do, the clinical examination of the patients in the wards,
the witnessing of all the important operations upon them and the performance
of post-mortem examinations upon those that die.

I cannot help feeling that the modern practice of entrusting surgical post¬
mortems to the non-practising pathologist, which is becoming the fashion now,
is in some respects a retrograde step. As a rule, the pathologist is much more
interested in medical than in surgical matters. He is almost necessarily
not interested in, or does not know, those little matters of surgical detail so
important to the operating surgeon, and consequently fails to record them in
his notes.

The loss to the young surgeon of this valuable post-mortem training is
surely obvious. Every young aspirant to a hospital staff who can do so, after
a year or two in the anatomy department, should soak for several years in
pathological museums, in operating theatres and in post-mortem rooms. He
can scarcely have too much of any of the three. He should devote all his
energies to learning his business and should neglect no opportunity of acquiring
knowledge that will be useful to him in after life. He must learn his
anatomy and surgical pathology thoroughly, he must watch the performance
of innumerable operations and see hundreds and thousands of clinical cases
before he is really fit to practise first-class general surgery, and to avoid
making mistakes when he comes across some condition which is a little out
of the common. Even then he will inevitably make mistakes. We all do.
But he will probably make fewer.

He must expect to have a hard time in his earlier days, and he will probably
find it difficult to make a living, unless he has private means, which few young
surgeons have. But he can earn enough to live upon by teaching, by giving
anaesthetics and in various other ways. He ought not to expect to do much
surgical practice of a remunerative kind until he has had ten or twenty years
of steady hard work at learning the elements of his profession. I know well
that it is a dog’s life, but for all that he is a happy dog who leads it!

Section of Surgery

Brilliant as are the results which have been attained in all operations in
which strict asepsis is possible and essential, I am not quite so sure that we
have any right to congratulate ourselves so much when we come to a totally
different group of operations. I mean those operations which are undertaken
where sepsis is already present. I refer more especially to acute suppurative
conditions of the abdomen. Not only is complete asepsis, from the very
nature of the case, impossible, but it is far more difficult for the young operator
to acquire the necessary experience for the correct treatment of these often
most difficult cases. It is easy enough by visiting great surgical centres, as
most of us do from time to time, to learn from the great masters of surgery, who
will often arrange their operations at a time which will suit our convenience.
But a surgeon cannot arrange for us an afternoon in which he will operate
upon, say, a fulminating appendicitis, a perforated gastric ulcer, a herniotomy
for gangrenous intestine, and an acute intestinal obstruction. Experience of
such operations is of the greatest importance to the practising surgeon. But
these are not operations that can be arranged in advance and demonstrated
before an admiring crowd of practitioners, or at a surgical congress. Many of
them, perhaps most of them, we perform at night, or at odd times, rarely
on regular operating days. Only long and assiduous attendance at hospitals
can enable young men to see much of them and thus to gain the experience
that is so needful. It is not so much mere technique that he requires for the
successful performance of such operations, but rather experience, the knowledge
of what to do and what not to do.

An operation which I think is performed too frequently is that for appendi¬
citis. It is of course quite true that the great majority of operations upon the
quiet appendix are easy of performance and almost devoid of danger. But
there is a minority in which the operation may be a very severe and difficult
one, and the difficulties both in diagnosis and in performance are not easily
foretold by the operator. When it is done for an acute condition, the risks
are naturally much greater, but the necessity of the operation may fully
justify the running of these risks. Where I venture to think most harm is
done is when the case is not seen in the very early stage of the disease, and
especially when the stage of abdominal distension has already been reached.
No one would wish to say that operation is never to be done in that stage.
But the risks then are undoubtedly much greater, and I sometimes wonder
whether it is realized sufficiently that, after all, most of such cases do not die
if not operated upon, and that the delay of a few days often puts the patient
in a much more favourable condition for operation if it has to be undertaken.
The matter is of course an extremely difficult and complex one, and I have no
wish to be dogmatic about it. I know of no rule as to when an operation is
to be undertaken for acute appendicitis, except that each case should be decided
upon its own merits, according to the judgment and experience of the indi¬
vidual operator. Nor do I wish to enter now upon the very difficult subject
of how to deal with these late and most dangerous cases of suppurative peri¬
tonitis. There can be little doubt that in the past there was a tendency to do
too much. In the nineties for instance, when surgeons were treating such
cases by free opening of the abdomen and washing out the whole peritoneal
cavity, the mortality was tremendous, as any one can see if he will take the
trouble to read the hospital reports of those days. Those were the days when
I, as surgical registrar, used to make many post-mortems upon such cases, and,
so far as I can judge from hospital records, my experience was much the same
as that of registrars at other hospitals.

Berry: The Progress of Surgery

Two operations for acute perforative peritonitis (not appendix cases) that I
witnessed about the year 1896 made a great impression upon me. Both were
in young women; both patients had perforated gastric ulcer; both cases were
similar in their origin and nature. One was operated upon within four hours,
and was treated by extensive washing out of the whole peritoneal cavity,
gallons of warm water being used for the purpose, until the peritoneum ap¬
peared to be perfectly clean everywhere. The patient nevertheless died in three
days. At the post-mortem, which I performed, the damaged peritoneum
showed little or no evidence of recuperative repair.

The other case was apparently a very much worse one. It was not seen
and operated upon until twenty-four hours had elapsed. The abdomen was
greatly distended, and the girl was extremely ill. I well remember the surgeon
saying, as he discovered the perforation and found extensive extravasation :
“ It is no use my trying to wash out this peritoneum — she will die if I
do.” So he merely gently mopped out fluid from the immediate neighbour¬
hood of the ulcer and closed the wound, inserting a drain. This patient made
a good recovery.

Since that time I have naturally seen numerous similar cases of both
kinds. The lesson that we have most of us now learnt is that it is generally
useless to attempt thorough cleansing of the peritoneal cavity, that the peri¬
toneum itself has enormous powers of repair, and that it is better in such cases
to interfere with it as little as possible, either closing the abdomen completely,
or at most putting in a drainage pipe.

In an address which I gave fifteen years ago, 1 after much study and experi¬
ence of the subject, I expressed the view that, “ if we were all to go back to the
old treatment of appendicitis that was in vogue twenty-five [now forty] years
ago, there would be a lesser mortality from appendicitis than there is at
present.” By all I mean not merely all hospital surgeons, but all who operate
for appendicitis. Fifteen years' further experience of the subject has confirmed
me in the opinion I then expressed. No one would wish to suggest for a moment
that experienced surgeons are not to operate for acute appendicitis, or even that
there are not many cases in which an immediate operation is imperative. But
I do think that much more care should be taken than is usual, in the selection of
cases for operation, both as regards time and manner. One of my earliest
lessons in surgery, one which I have never forgotten, and which has been of
great use to me in practice, was taught me by my friend and former teacher,
the present President of the Royal College of Surgeons. Referring especially
to the operative treatment of acute inflammatory conditions, he used to
say : “ Think, before you decide to operate, what is likely to be the natural
course of the disease if it is not operated upon, and what possible harm
your operation itself may do.” I think that many of the operations for
inflammatory conditions of the abdominal viscera and particularly of the
appendix, are too often undertaken without due consideration of this
important point, and especially when the operator is a man of small
experience.

It is commonly believed and stated both by the public and by the pro¬
fession that the modern custom of operating freely for acute appendicitis has
resulted in great saving of life. But is this really the case ? If it were, surely
deaths from appendicitis would be less common now than they used to be;
unless we may assume, as some boldly do, that appendicitis is a disease that

1 Lancet, September 7, 1907, p. 680.

Section of Surgery

is becoming increasingly frequent. I see no reason for thinking that this really
is the case, although undoubtedly it is far more frequently diagnosed, and has
attained much greater prominence in the eyes both of the public and of the
profession.

As food for serious reflection, and I do not claim anything more for them, I
would draw your attention to the figures in these tables which I have com¬
piled from the Registrar-General’s returns. Statistics may be very misleading
and want very careful examination before they can be accepted as proving
anything. But these figures, if they mean anything, tend at least to show
that the mortality from appendicitis has not diminished since the custom of
operating for acute appendicitis has been so widely prevalent. Greater accuracy
in diagnosis and in registration will account for some of, but not, I think, for
all, the increased mortality.

Table I shows the total deaths from appendicitis in quinquennial periods
since 1901. How many of these deaths followed operation we cannot say, and
it is of course open to anyone to say that most of the deaths occurred because
the cases were not operated on.

Table II shows the corresponding figures for peritonitis, and is a good
illustration of one danger of the use of statistics. Taken by itself it might be
interpreted to mean that deaths from peritonitis had diminished greatly in the
last twenty years. The true explanation is doubtless that, owing to increased
accuracy of diagnosis, many deaths that would have been registered in Table II
now come into Tables I, III and IV. I give you, therefore, Table V, as well,
which shows for the same periods all the deaths from all diseases of the
digestive system arranged according to the Registrar-General’s classification.
Some curious points appear among these figures. Why, for instance, deaths
from gastric ulcers in males should have risen apparently from 2,683 to
5,195, while those in females have diminished from 5,703 to 4,455 is not
clear to me.

Table I.—Total Deaths from Appendicitis and Perityphlitis.

England and Wales (compiled from Registrar-General’s Reports).

Period

Male

Female

Total

1901-05

. 4,878

3,418

8,291

1906-10

. 6,299

4,587

10,886

1911-15

. 7,260

5,480

5,591

12,740

1916-20

. 6,827

12,418

Table II.— Total Deaths from

Peritonitis (Non-puerperal).

England, and Wales (compiled from Registrar-General’s Reports).

PnriCKl

Male

Female

Total

1901-05

. 2,500

2,960

5,460

1906-10

. 1,549

1,875

3,424

1911-15

. 1,118

1,627

2,740

1916-20

. 885

1,270

2,155

Table III.— Total Deaths from Intestinal Obstruction.
England and Wales (compiled from Registrar-General's Reports).

Period

Male

Female

Total

1901-05

. 6,832

6,427

12,759

1906-10

. 6,511

6,469

12,980

1911-15

. 6,aso

6,302

12,632

1916-20

6,565

6,412

12,977

Table IV.— Total Deaths from Gastric Ulcer.

England and Wales (compiled from Registrar-General’s Reports).

Period

Main

Ken.ale

Total

1901-05

. 2,688

5,703

8,386

1906-10

. 8457

5,329

8,786

1911-15

. 4,532

4,842

9,374

1916-20

. 5,195

4,455

9,650

Berry: The Progress of Surgery

OUu*r (liKeasi-^ of digestive systom ...| 1,238 1,21 P> 2,454 882 913 1,795 641 551 1,195 495 172 967

Section of Surgery

One frequently hears it said that the war has produced great advances in
surgery. No doubt in many directions it has done so. One has only to point
to the great improvements in the treatment of septic wounds, of compound
fractures, and to the brilliant results obtained in the plastic surgery of the face
and other parts. No one can see without admiration the wonderful work
that has been done on bones, joints, muscles and nerves at the many
military orthopaedic hospitals. But in another respect the war has had a
harmful effect.

All over the country at the present time large and dangerous operations
are being undertaken by those whose qualifications for undertaking them
consist chiefly in a few years of practice in military surgery, the surgery of
injuries, of injuries inflicted for the most part upon young and previously
healthy men.

No doubt the surgery of gunshot wounds, of compound fractures, and the
subsequent deformities resulting from them form an important branch of
surgery. But this kind of surgery forms but a very small portion of civilian
general practice. Great experience of military surgery does not in itself
qualify an operator to deal satisfactorily as regards either diagnosis or treatment
with such important subjects as diseases of the breast, cancer of the tongue,
tumours of all kinds, diseases of the biliary passages, of the stomach, colon,
prostate, &c. And yet how often do we hear of practitioners with little more
than a few years of military experience behind them, gaily and almost light-
heartedly undertaking the gravest operations for conditions such as the above,
with little knowledge of the dangers to which they are subjecting their patients.
If the case happens to be a straightforward one that can be dealt with by a
text-book operation all may go well. But only too often some unexpected
difficulty or complication arises for which the operator is wholly unprepared,
and the result may easily be disastrous for the patient. Almost every large
town in England at the present day has one, or more than one, skilled
surgeon who is devoting himself, after long training and experience, to the
exclusive practice of surgery 7 . It is therefore, I think, unwise for those who
have not had this special training and experience to undertake extensive and,
if improperly performed, dangerous operations (except in cases of great
urgency) when there is generally someone close at hand more competent to
perform them.

The student who sees the modern surgeon at work, whether in a London
or provincial centre, is perhaps too apt to imagine that after all operative
surgery is a very easy matter. He thinks that he has only to exercise surgical
cleanliness, to which nowadays everybody is trained, and that he can then do
with impunity the largest and most dangerous operations of surgery that he
has seen his teachers doing. Later on, when he gets into practice, especially
if he has been fortified by the experience of a few years of war surgery, he is
only too apt to find that the actual practice of operative surgery is not quite
so easy as he has imagined. He may for instance do many simple inguinal
hernias, and some day he will find a puzzling case ; and it is not until he
has opened the herniated bladder that he learns what this condition looks like
in the living, and that it is a more common occurrence than he had previously
imagined.

Since these remarks of mine were written, my attention has been called
to a tragic and pathetic story recently written by Sir Frederick Treves in his
usual masterly and inimitable style. It concerns a young man who had had
a distinguished hospital career, had taken the Fellowship of the Boyal College

Berry: The Progress of Surgery

of Surgeons, and had then started practice in a humble country town. He
considered surgery to be his mttier, although hitherto he had had but little
opportunity of actually practising it. A serious operation has to be done on a
member of his own family and, at the earnest wish of the patient, he consents
to operate himself rather than send for a surgeon of more experience from a
neighbouring town. The operation proves more difficult than he, in his
inexperience, had anticipated, and, as the direct result of it, the patient dies.

The story is told in the guise of fiction, but who can doubt that it is
founded on fact. There are probably few of us who do not know of actual
cases very similar to that related by Sir Frederick. I strongly recommend
everyone to read the story. It is published under the title of “ The Idol
with Hands of Clay,” in the July number of Cassell's Magazine .

I had intended to say something on the thorny subject as to where the
dividing line should be drawn between the practice of the general surgeon and
that of the specialist. I have heard of gynaecologists who operate for appendi¬
citis and even upon gall-bladders, of laryngologists who venture to undertake
deep dissecting operations at the root of the neck, a region with which they are
not necessarily familiar. On the other hand, some general surgeons have been
known to stray into fields which had better be left to the specialist. This
subject would doubtless have excited a lively controversy, but my time is
short, and I will merely tell you a short story which bears upon it.

Many years ago, in the days when gynaecologists were beginning to do
abdominal surgery, I went by chance into an operating theatre, where an
elderly gynaecologist was at work. His previous training had been wholly that
of a physician, with the exception of what he had received from bis surgical
colleagues, who had taught him the rudiments of abdominal surgery by helping
him at his earlier ovariotomies and hysterectomies.

On this occasion I found him in a state of considerable excitement and
sweating profusely. An open abdominal wound had about twenty pairs of
forceps on a retroperitoneal mass that he was struggling to remove. He
called to me to tell him what it was. A glance was sufficient to enable one to
say that it was a solitary horseshoe kidney lying over the promontory of the
sacrum. No one with any training in surgical anatomy or pathology could
have failed to recognize its nature. He tied off the vessels that had already
been cut and closed the wound.

At the post-mortem next day it was found that both renal arteries and
ureters had unfortunately been tied before the mistake was discovered.
It transpired that the woman had come to his out-patient department
complaining of some trivial complaint. He had discovered accidentally an
abdominal tumour and thought he would like to remove it. It was a singular
and striking instance of a man straying into a field of practice which did not
really belong to him.

On the other hand it must be admitted that the general surgeon will
sometimes also make serious mistakes when he undertakes operations with
which the gynaecologist, now at least, is more familiar than he. An accident
which I have never actually witnessed, but which I know has occurred several
times at the hands of general surgeons, was once celebrated by some waggish
student (whose name I do not know) in the following lines of doggerel:—

There was a young woman named Mopsy,

Who had an ovarian dropsy ;

When they plunged in the trocar

A voice exclaimed, “ Ma I

They’re hurting your own Popsy Wopsy.”

Section of Surgery

He was evidently referring to some operation he had actually seen. I have
also known a distended bladder opened by mistake for an ovarian cyst with
a fatal result. Both these cases occurred more than twenty-five years ago.

I hope that it will not be thought that I have been unkind in relating the
mistakes and failures of other surgeons, most of whom are now dead. Some,
but not all, of these errors occurred at hospitals to which I have myself been
attached. Some of the surgeons were my early teachers whose memory
I cherish with feelings of gratitude, respect and affection. I am sure, that,
were they alive, they would rejoice to think that their mistakes should have
been utilized for the instruction of others. Indeed I hope that in the future
some pupil of mine, who has been warned by the many mistakes and failures
that I have myself made, may utilize them for the benefit of a new and more
perfect generation. We learn as much from errors that we make ourselves, or
see others make, as by our successes.

I have often been asked what is my definition of a good surgeon. Many
answers might be given to this question. My favourite is : “ One who always
knows when to put in and when to take out a drainage tube/’ to my mind
often one of the most difficult problems in general surgery. It is a matter that
cannot be learned from books, but only from experience.

For the conclusion of this address I think I cannot do better than quote
the description of a surgeon given recently by Sir Frederick Treves in language
better than any that I have at my command: 1 —

“ A good surgeon is bom not made. He is a complex product in any case, and often
something of a prodigy. His qualities cannot be expressed by diplomas nor appraised
by university degrees. It may be possible to ascertain what he knows, but no
examinations can elicit what he can do. He must know the human body as a forester
knows his wood: must know it even better than he, must know the roots and branches
of every tree, the source and wanderings of every rivulet, the banks of every alley, the
flowers of every glade. As a surgeon, moreover, he must be learned in the moods
and troubles of the wood, must know of the wild winds that may rend it, of the savage
things that may lurk in its secret haunts, of the straggling creepers that may throttle
its sturdiest growth, of the rot and mould that may make dust of its very heart. As an
operator, moreover, he must be a deft handicraftsman and a master of touch.

44 He may have all these acquirements and yet be found wanting; just as a man
may succeed when shooting at a target, but fail when faced by a charging lion.
He may be a clever manipulator and yet be mentally clumsy. He may be even
brilliant, but Heaven help the poor soul who has to be operated upon by a brilliant
surgeon. Brilliancy is out of place in surgery. It is pleasing in the juggler who plays
with knives in the air, but it causes anxiety in an operating theatre.

“ The surgeon’s hands must be delicate, but they must also be strong. He needs
a lace-maker’s fingers and a seaman’s grip. He must have courage, be quick to think
and prompt to act, be sure of himself and captain of the venture he commands.
The surgeon has often to fight for another’s life. I conceive of him then not as
a massive Hercules wrestling ponderously with Death for the body of Alcestis, but
as a nimble man in doublet and hose who, over a prostrate form, fights Death with
a rapier.”

1 Cassell's Magazine. July, 1922.

Section of Surfler\>.

SUB-SECTION OF PROCTOLOGY.

President of Sub-section—Sir Charters Symonds, K.B.E., C.B., M.S.

Gonorrhoeal Stricture of the Rectum ;

PRESIDENT’S ADDRESS.

By Sir Charters Symonds, K.B.E., C.B., M.S.

[After referring to the loss sustained by th6 death of Sir Charles Ryall,
who had been elected President of the Sub-section at the close of the last
Session, Sir Charters Symonds continued]:

I HAVE selected a subject for my address upon which there is no little
difference of opinion. I propose to confine my remarks to one form of cica¬
tricial stricture, a variety which I have always regarded as possessing a
definite entity, and as being due to gonococcal infection.

Let me first describe the form of stricture to which I wish to refer. It is
that which involves (in the majority of cases) the lower 3 or 4 in. including the
anal margin, but in some cases reaches into the pelvic colon (fig. 1). It affects
the whole circumference of the bowel; it is characterized by bands and bridles
of indurated and fibrotic muscle, between which are pockets, from the bottom
of which fistulous tracks may lead into the vagina or on to the surface round
the anus. The extreme narrowing occurs at several points, and is so tight in
advanced cases as to prevent digital examination or the passage of a small
bougie. One characteristic is the presence of hard polypoid growths ringing
the anal margin, a condition not seen to the same extent in any other form of
stricture, except that sometimes attributable to dysentery. The history given
by the patients is that of discharge from the rectum, together with difficulty in
defaecation extending over some years. In married women these symptoms
frequently date from the early days of wedded life, in others, where inter¬
course has been promiscuous, the patients are often younger—aged, say, 25—
and a definite history cannot be obtained.

Seven cases of this malady have come under my observation, all occurring
in women. Five were under my own care, and two were observed while under
the charge of others. Let me call attention to these cases, and briefly relate
the symptoms and complications in two of them.

Case I.—The first was that of a woman, aged 41, who was admitted to Guy’s
Hospital in June, 1887, under Dr. Goodhart, and later transferred to my care, for
rectal stricture and abdominal pain, chiefly in the sigmoid region. She was extremely

[ATorenifor 8, 1922.

Section of Surgery: Sub-section of Proctology

emaciated, and for three years had had a discharge from the rectum. The stricture
began at the anus, and was too narrow to admit the finger; pus and blood were dis¬
charged with thin acrid faecal matter.

She stated that soon after her marriage in 1863, twenty-four years before, she had
syphilis, and was severely ill for some months. There was a perforation of the palate
but no other evidence of syphilis. A lumbar colostomy was performed, and it was
observed that the bowel looked unusually thin. Though relief was afforded the patient
never showed any sign of improvement generally, and suffered a good deal from
abdominal pain, occasional diarrhoea, and frequent vomiting. Pus at times in con¬
siderable quantities escaped from the artificial anus and occasionally per rectum . The
temperature was of the hectic type, the pulse quick and feeble, the tongue dry and
glazed. Irrigation of the colon did not appear to affect the discharge of pus. She
died four months after operation from exhaustion.

The stricture as shown at autopsy involved 3 in. of the rectum, and at two points
the narrowing was extreme. The cause of death was seen in the caecum, for this part of

Fig. 1.

the bowel together with the greater part of the ascending colon was dark red and
gTanular from multiple points of ulceration. The rest of the colon and down to the
stricture was healthy. There was no lardaceous disease. There was a hard cartilaginous
mass in the diaphragm, apparently an old gumma. There can be little doubt that this
patient suffered from syphilis, but it is most probable she had also had gonorrhoea.

The next case shows the destructive effects of long obstruction:—

Case II .—A woman, aged 41, admitted under my care in May, 1907, for rectal
stricture and the constant discharge of thin foul-smelling material. Twenty years ago,
soon after her marriage, she had pain in the rectum accompanied by a brown discharge,
a condition that has existed more or less ever since. The patient was wasted and ill,
and in much suffering, and was constantly worried by the rectal discharge. The anus
was surrounded by the usual hard pendulous masses, the finger could be passed for a
distance of 2 in., and was then arrested ; the surface between this point and the anus

14 Symonds: Gonorrhoeal Stricture of the Rectum

was devoid of mucous membrane, and marked by hard ridges and pockets. The
abdomen was somewhat distended, and there was some hypertrophy of the bowel.

On May 4 left inguinal colostomy was performed. Examination showed that the
thickening and hardness extended up to the sigmoid, and there were adhesions between
the broad ligaments, rectum and pelvic wall. The bowel was not opened. The next
day the temperature rose to 100° F., the pulse to 104. On the third day it reached
103*6° F., and the pulse 130. There was some sickness but no distension. On the
fourth day the bowel was opened and washed out. The material escaping was brown,
thin, and foul smelling, and ran out continuously, the margins of the wound became black
and the surrounding skin inflamed. The patient began to emaciate, the tongue, the
mouth, and the skin became peculiarly dry, w'hile the odour exhaled from the body was
most disagreeable. The colon was irrigated with saline and various antiseptics without
relief. On the sixth day the temperature was 96*2° F. to 97° F., and remained so to
the end. The pulse fell to 88 and 98 by the tenth day. The amount of nourishment
taken was small. She was frequently sick and was losing ground. On the twentieth
day the appendix was opened, sutured to the abdominal wall, and the colon irrigated.
Next day there was a marked improvement. The tongue was less dry, she looked less
dried up and took more nourishment, and we had hopes of her recovery. The colon
was irrigated through the appendix twice daily, on some occasions with hydrogen per¬
oxide, but each day it seemed to cause more distress, and had to be abandoned. The
green foul discharge disappeared, but the downward progress was steady. The skin
round the artificial anus had sloughed from the contact of the acrid discharge. She
died on May 81, just four weeks from the operation.

At the autopsy the mucous membrane was grey and cicatrized from the anus up to
the colostomy opening. The lower 8 in. were marked by dense thickened masses, with
intervening pockets. Further up, the wall was thickened, and though the lumen was
not seriously contracted, there was general ulceration. The caecum and colon did not
show any ulceration as had been anticipated, nor was any other morbid condition
found.

The fatal termination was unexpected, for the patient had been doing her
ordinary household work up to the time of her admission. The rise of tempera¬
ture immediately after the operation may have been due to the injury, slight as it
was, to the wall of the bowel. The rapid emaciation after the bowel was opened,
the inability to take food, the remarkable dryness of the tongue and mucous
membrane of the mouth and of the skin, were no doubt due to absorption of
toxins from the colon and edges of the wound. During this period it will be
remembered that the temperature was 97° or under. The rapid change in the
colour of the thin fluid escaping from the bowel—from brown to green—and the
sloughing of the skin, together with the disagreeable odour of the body, were in
part due to starvation, and diminished when nourishment was taken. The
improvement following irrigation through the appendix was brief, and yet so
definite that for a few days one could not but regret that it had not been
adopted earlier. One surmised that, as in the previous case, the ulceration
would have been found in the caecum, and if so, probably greater benefit would
have resulted.

This case exhibits the secondary effects of obstruction of long duration and
points to the necessity for early colostomy. It would appear that the injury
of the operation determined the onset of an infection, which, held in abeyance,
only needed some such cause to set it alight. It is comparable to a case to be
mentioned later, in which a digital examination determined profuse diarrhoea
and death in twenty-four hours.

Case III .—A woman aged 40, the wife of a hotel proprietor, and therefore in easy
circumstances, had a typical impassable stricture. She was in good health and well
nourished and was relieved by a colostomy. She had had symptoms for some years
and there was no evidence of syphilis.

Section of Surgery : Sub-section of Proctology

Of the other cases one, as just mentioned, died after a digital examination.
This was, I believe, an attempt to force the finger through the stricture, and
caused some pain. The most profuse and continuous escape of thin, evil¬
smelling fluid followed, and death from collapse. In another the polypoid
masses were removed, but whether a rectal examination had been made
I cannot say. The result was disastrous, for death from acute septicaemia
took place in a very short time. These two cases I saw while Surgical
Registrar in 1880-82.

In two cases removal was attempted after colostomy. In one where the
finger could reach healthy bowel the operation was completed and the
colostomy wound closed ; the anal control was fairly efficient. I may
mention that an interval of six months was allowed to elapse between the
colostomy and the excision, to permit of the subsidence of any existing
periproctitis. In the other, after extending the dissection up to the peritoneum
without reaching healthy bowel the operation was abandoned. The feasibility
of excision can usually be ascertained at the time of the colostomy.

In all seven cases the stricture was of the character described in the earlier
part of this communication.

What is the cause of this form of stricture? The appearances show clearly
that it is the result of cicatrization following upon a deep and widespread
ulceration. As to the cause of this ulceration there is no unanimity of opinion.
Many of the museum specimens are labelled syphilitic, a nomenclature adopted,
it would appear, more or less from tradition and without adequate investigation.
It is a well established observation that this variety occurs almost exclusively
in women, an incidence demanding a local explanation. Were it due to any
constitutional condition, such as syphilis, it should be encountered with equal
frequency in the male subject.

Let us first consider the question of sex. The seven cases were, as I have
said, all women. Turning to museum specimens there are at Guy’s Hospital
thirteen available for classification, of these ten are from women and three
from men. The youngest amongst the women was 22, two were aged 25,
two 42, and the remaining five were between 30 and 40. Where the genitalia
are attacked there is evidence of local peritonitis as is shown by adhesion of
tubes and ovaries, a well recognized effect of the extension of a local infection
usually attributed to gonorrhoea.

The three specimens from men show characters identical with those from
women, including in one well-marked polypoid anal masses. In some of the
cases from women there was in the body evidence of old syphilis, and while
this association is not mentioned in the history given in the three cases from
men, no particular importance can be attached to the omission one way or
the other.

Death was directly attributable to the effect of the stricture in several of the
cases, e.g., from peritonitis, septic extension, prolonged diarrhoea and exhaustion,
lardaceous disease—in a man who passed 5 to 6 oz. of pus daily for two years—
while others died from phthisis—one of these having tuberculous ulceration
of the ileum—another from pneumonia. In one death was due to pyaemia,
probably following the use of bougies.

I find similar specimens in other museums in London :—

(1) In St. Thomas’s Hospital: Two, both from women.

(2) Middlesex Hospital: One, also from a woman.

(3) St. Bartholomew’s Hospital: Eight; seven from women and one
without sex being indicated.

16 Symonds: Oonorrhceal Stricture of the Rectum

(4) London Hospital: Seven, four of which are from women, no sex being
indicated in the other three.

(5) Royal College of Surgeons: Seven, three of which are from women and
two from men. One of these latter is very typical, showing bridles and pockets.
It came from a man of middle age who had used bougies. The other is a
Hunterian specimen (2571), and shows ulceration and narrowing of the whole
rectum and part of the colon.

There are thus in the museums examined thirty-eight examples, of which
twenty-seven are from women, six are from men, and five are unspecified.
If the seven cases seen during life be added, we get a total of forty-five cases,
thirty-four of which are from women and six from men, a difference of
incidence calling for some explanation.

In the descriptions in the catalogues of the museum specimens, are found
such remarks as: “ Suffered from syphilitic disease of the rectum ” ; “ affected
by what was supposed to be tertiary syphilis ”: “ supposed to have resulted
from syphilis.” Others are frankly called: “ Syphilitic ulceration,” or
“ destruction from syphilitic ulceration,” or “ the stricture was due to syphilitic
ulceration ”; again, “ syphilitic stricture of the rectum ” ; others, and in
appearance identical, included in my list are simply labelled “ fibrous stricture.”

Thus it will be seen that while some observers have been wisely doubtful,
others have not hesitated, yet the stricture in all is of the same type. In a few
there has been evidence of syphilis in perforation of the palate, a cicatrized
gumma, and lardaceous disease. The occurrence of both syphilis and gonor¬
rhoea in the prostitute class is to be expected, and not much evidence of
constitutional disease can be adduced from a museum specimen in the absence
of a clinical history: on the other hand, in those observed during life—
five cases—there was no evidence of syphilis.

To establish the infective view information is required as to the early stage
of gonorrhoeal proctitis. Not much information is available, nor am I in a
position to communicate any personal observations. My friend, Dr. Stebbing,
of the Lambeth Infirmary, has been good enough to supply me with some
notes of cases admitted under his care. He writes :—

“ I find that I have brief notes of seven cases of definite gonorrhoeal proctitis in
which the diagnosis was confirmed by bacteriological examination, and in three
of which proctoscopic examinations were made. Six of the cases are in women of the
prostitute class, and one in a man who had at the same time gonorrhoeal urethritis.
One of the cases had already proceeded to the stage of stricture, and three of the cases
showed 4 Paget's cocks’-combs ’ well marked.”

He tells me further that the mucous membrane showed numerous small ulcers,
over all parts, and in one case these reached into the pelvic colon.

Few as these observations are, I think it will be allowed that they establish
the existence of gonorrhoeal proctitis. I by no means wish it to be inferred
that the observation is new, or that the disease has not been described. The
observations are valuable also from their completeness. There is a vagueness
in many of the accounts one comes across. Writers on syphilis and gonorrhoea
admit gonococcal proctitis in both sexes. Thus McDonagh says: “ Owing to
the proximity of the anus and vagina, gonococcal proctitis is more common in
women than in men. It occurs in a higher percentage of cases than is generally
thought.” This author describes the mucous membrane as “ red, swollen and
granular, bleeding easily when injured, and there are usually several erosions,
some of which may be covered with a sort of membrane. Only rarely does
true ulceration occur, which is sometimes followed by stricture.”

Section of Surgery: Sub-section of Proctology

Does the occurrence in the male weaken the position and lean the balance
in favour of a constitutional cause ? First, as to the similarity of the stricture
in men with that already described in women, I would call your attention to
this specimen from the Guy’s Hospital museum (fig. 2). The limitation to the
lower 3 or 4 in., the involvements of the anal margin, the marked pendulous
masses, the ridges and pockets are all present. There can be little doubt that
it is due to the same cause. The other specimens from those referred to show
more or less the same characters, and it will be remembered that there were
six collected from the museums as against thirty-four clinical and museum
examples from women. In the case of the man mentioned in Dr. Stebbing’s
note, ulcers were present, and he had definite gonorrhoeal urethritis but no
signs of syphilis, the Wassermann reaction also being negative. This case

Fig. 2.

establishes the occurrence of gonococcal proctitis, in the absence of syphilis,
in the male, and emphasizes the view that the stricture under consideration is
in both sexes due to this mode of infection. Writers on this subject, for the
most part, accept a syphilitic basis for this form of stricture, describing, how¬
ever, what appears to be an identical disease as “ cicatricial stricture,”
without any causal relation. Others are less decided, thus Mr. Mummery
writes, in his book on “ Diseases of the Rectum and Anus ” :—

u While I am not in a position to deny that syphilis may be a cause of rectal
stricture, personally, I have never met with a case of syphilis of the rectum (including,
of course, condyloma of the anus and chancre), and at St. Mark’s Hospital there is no
reliable record of a case of tertiary syphilis of the rectum or of a syphilitic stricture.”

And again he says :—

44 It is well known that antisyphilitic treatment does no good in cases of rectal
stricture.”

Symonds: Gonorrhoeal Stricture of the Rectum

A careful, and it seems to me, well-considered opinion is expressed in
Thomson and Miles’s “ Surgery,” and is as follows :—

“ The commonest cause of non-malignant stricture of the rectum is chronic pyogenic
infection, probably in most cases of gonococcal origin.

“ The proportion of syphilitic cases has been exaggerated on account of the tendency
to attribute to syphilis all strictures in which no other definite cause can be dis¬
covered. 1 *

With this view I fully agree, and it supports my plea that the nomen¬
clature is largely a matter of tradition, and has been adopted without full
investigation.

The following statement is made in the American “ Treatise on Diseases of
the Kectum and Anus,” edited by A. B. Cooke:—

“We must record our conviction that gonorrhoeal infection and syphilitic ulceration
must be reckoned with in a great majority of cases.

“ I have observed 100 cases of fibrous stricture in the rectum and 75 per cent, of
that number was traced to syphilis, including five due to chancroidal ulceration.”

This rather suggests that when syphilis existed the stricture was set down
to this disease. One would require information as to the presence, recent or
remote, of gonorrhoea before accepting so large a proportion as due to syphilis.
Moreover, from the observations above related, one would be inclined to
question the syphilitic origin of any of the cases.

The chief reason in favour of this form of rectal ulceration and stricture
being determined by a local cause is its prevalence in women; clinically, I
have never seen it in men. The easy access of discharges from the vagina to
the rectum in women is obvious. I am not prepared to deny that the secretions
from chancres do not determine the ulceration, but I would submit that the
disease is due to local and not constitutional causes, otherwise it should occur
as frequently in men as in women. Nor can it be asserted that syphilis is
wholly absent and it is possible that local irritation may determine a syphilitic
deposit. Gonorrhoea is, we know, a far more frequent infection than syphilis,
and the well-known tendency to the formation of cicatricial contraction is seen
in the male urethra. Again, the occurrence of adhesions of the Fallopian
tubes and ovaries found in these cases supports the view that gonorrhoea has
existed. A local infection in the male is not by any means impossible where
inattention allows the discharge to collect on the clothing; and there is, I am
informed, amongst a particular class, a more direct mode of infection. Since
the public are better informed and better treated and take a more serious view
of a malady that at one time was treated as a joke, rectal complications will,
no doubt, be less frequent.

Whatever view we adopt, whether it be that of a pure gonococcal infection
or one of a mixed character, I submit we cannot assign constitutional syphilis
as the cause. It will be nearer the truth to speak of this form of rectal
stricture as due to local infection from the labial and vaginal discharges, and as
the most frequent disease is gonorrhoea, to call it “ gonorrhoeal stricture.”

Treatment.

(l) Bougies .—Use of bougies in the early stages has its rightful place, but
in more advanced stages I question the wisdom of this method, and would
certainly limit it to those cases where healthy bowel can be reached by the
finger. If employed where a limit cannot be reached, a perforation may be
made with fatal consequences through a thin-walled pocket of ulceration. The
danger attending a too rapid dilatation needs remark. The fatal result of a

Section of Surgery: Subsection of Proctology

single digital examination I have mentioned and the forcing of a bougie through
a stricture may be followed by septic infection. As in urethral stricture, a
bougie fitting loosely and left in some hours will do more good than one that
fits tightly.

(2) Division .—The same limits should, in my opinion, be set to division,
seeing that the disease may extend into the pelvic colon.

(3) Excision .—This again, I take it, is applicable to those cases in which a
limit can be reached by the finger. I have been successful in one case, and
have had to abandon another. What success has attended the endeavours of
others with a larger experience?

(4) Colostomy .—This method occupies a foremost place in the manage¬
ment of these cases, and in the advanced forms constitutes our one and only
means of relief. As a preliminary to excision I would consider it essential,
and its performance before incision appears to be a wise step to take.

(5) Cipcostomy .—In long standing cases such as I have described at the
beginning of this paper, in which from the character of the rectal discharge
ulceration may be presumed to exist, csecostomy as a primary operation would
seem to be indicated. Had this been adopted in the first case in which the
ulceration affected the caecum and ascending colon, a better result would
probably have resulted. And in the second, though the ulceration was in the
ascending colon, the removal of faecal infection could only have been
beneficial.

(6) Appendicostomy was quite successful as a means of irrigating the
colon in the one case referred to, and though marked improvement resulted
at first, this was not maintained, and irrigation had to be abandoned on
account of the pain it occasioned.

DISCUSSION.

Mr. Sw in ford Edwards said that when he was a student most strictures of the
rectum when not malignant were supposed to be syphilitic but this view had long been
exploded. He personally had never seen a syphilitic rectal stricture though he had
seen stricture in patients who were also the subjects of syphilis. Excluding carcinoma,
tubercle, dysentery and traumatism, gonorrhoea w T as probably the cause of the remaining
strictures, w’hich meant that it was the origin of most fibrous strictures of the rectum,
otherwise how could one account for the large preponderance in women, who suffered
from gonorrheal infection of the rectum much more frequently than men did ? He was
therefore in full accord wdth the conclusions of the President. Regarding the two cases
which were illustrated by the epidiascope : he asked w hether they might not have
been tuberculous, for they much reminded him of some cases of this condition which
had been under his care and which were undoubtedly tuberculous. As to treatment, he
recommended hypogastric colostomy for those cases of tubercular stricture extending to
the upper rectum, or even beyond. Excision was risky and nothing much to be gained
by it. For strictures within three or four inches of the anus—posterior linear proctotomy
was the operation of choice as it afforded good drainage and in this respect was a safer
operation ih Mr. Edwards’s opinion than an internal proctotomy even when supple¬
mented by division of sphincter. He mentioned the case of an officer with multiple
tight fibrous strictures of the rectum and colon, due to poisoning by ground glass.
The treatment consisted of appendicostomy and subcutaneous injections of fibrolysin.
The patient made a good recovery and after some months was passing normal sized
stools. Mr. Edwards heard afterwards that wisliing to get rid of his appendicostomy
he got admitted into a military hospital where an operation took place to wffneh he
succumbed.

Dr. LAPTHORN Smith said that they were all very much indebted to Sir Charters
fcymonds for the very thorough and painstaking work shown in this paper which was the
very last word on the subject. There were very few Fellows of the Society who would
have gone to the trouble of visiting the museums of the great hospitals actually to find
out for themselves what w*as to be learned from these specimens. He had shown that

20 Symonds: Gonorrhoeal Stricture oj the Rectum

this disease of the rectum was due to gonorrhoea and not to syphilis, which was of great
importance when it came to the treatment. Dr. Lapthom Smith had had under his
care only one case of venereal stricture of the rectum and he had lost much precious
time in treating it as a case of syphilis instead of gonorrhoea to which they now knew
it to be due. This unfortunate patient, whom he attended nearly forty years ago,
had a long thick stricture of the rectum composed of very friable tissue. If he were to
have such a case to-day, with the knowledge which Sir Charters had placed in our
possession, he would treat it with injections as a case of gonorrhoea anyw T here else.
If that failed he would do a colotomy and about six months later if the inflammatory
thickening had not subsided he would remove the rectum and bring down the intestine
and attach it to the sphincter. In one case he had done for cancer the woman had
perfect control and lived in comfort for many years after. If after removal of the
rectum for stricture the woman had control of the sphincter the colotomy might
be closed subsequently. At one time he had used a great deal for various strictures,
metal bulbs, to which was attached the negative pole of the galvanic current, with very
good results, as the galvanic current seemed to favour the absorption of fibrous deposits.
Perhaps this might be tried in gonorrhoeal strictures before resorting to the major
operation.

Mr. Aslett Baldwin said that about the middle of 1919 he saw a young woman
who was very ill with intestinal obstruction of five days’ duration. A year previously
she had been in a hospital for four months, where she was treated for
gonorrhoea associated with abscesses, which had been allowed to burrow extensively.
There was a large mass in the left side of the abdomen, which was the loaded
colon. There were several anal fistulae, and one recto-vaginal fistula. About
2 in. up the bowel there was a stricture, which would not admit the end of the
index finger. Eventually the bowel was cleared in a nursing home. Mr.
Baldwin operated on the fistulse and dilated the stricture to 22 Hegar. The patient
had been passing bougies herself daily. Mr. Baldwin had seen her about every fortnight,
and had passed bougies and given negative ionization. She had long been in excellent
health. She ceased attending about a year ago. He (Mr. Baldwin) received a letter
from her about a month ago, thanking him for all he had done, and saying she
had been instantaneously cured in mind and body by Christian science.

Mr. Lockhart-Mummery said he thought it unwise to label these strictures as
being due to any one specific cause. He believed they resulted from chronic sepsis,
due to any cause, and although the preponderance of cases among women suggested
gonorrhoeal origin, it was. probably secondary septic infection, resulting in a stricture
rather than a specific infection. Mr. Lockhart-Mummery said he had seen in all
about three cases of gonorrhoeal proctitis, but none of these had resulted in a stricture
of this nature, which was probably due to the fact that they were properly treated. He
had seen this form of stricture result from many different causes, such as operations
upon the rectum followed by sepsis, glass poisoning, tubercle and scalds. One patient
at a large hospital was given a boiling enema by a nurse, and a similar case occurred
only recently in a nursing home, with stricture resulting; and stricture used to be
common as a result of sepsis in St. Mark’s Hospital before the days of antisepsis, and
was then no doubt the result of infection from dirty enema nozzles, &c. His own belief
was that these cases of stricture of the rectum resulted from neglected chronic sepsis
due to any cause. Rectal strictures were certainly far less common at present than
they used to be, this being doubtless due to the fact that they were now much'more care¬
fully treated in the early stages. As regards treatment, Mr. Lockhart-Mummery agreed
with the President in thinking that the majority of cases were best treated by means
of proctotomy where the stricture was strictly localized and did not reach above the
peritoneal reflexion. He thought internal proctotomy would give excellent results,
and he had had^quite a number of cases in which this has been successfully done.

Mr. Lionel Norbury asked for an opinion as to the relative advantages of
internal proctotomy and excision in cases of stricture of the rectum situated below the
level of the peritoneal reflection. He considered that treatment after internal
proctotomy by means of bougies, &c., must needs be continued for a very long
time, with much discomfort to the patient, and that such treatment was not always
satisfactory. He was also of opinion that excision should be carried out when possible
for strictures low down in the rectum.

Section of Suroers.

President—Mr. James Berry, F.R.C.S.

On Subcapsular Pyelotomy, with Remarks on the Origin and
Treatment of Renal Calculi.

By W. Sampson Handley, M.S., F.R.C.S.

It is usually held that renal calculi form either in the pelvis or in the
calyces. Sir J. Thomson-Walker appears to regard it as very doubtful whether
a calculus can form in the renal substance. He says: “ It is said that a
calculus has rarely been found embedded in the substance of the kidney and
unconnected with the calyces. I have not met with such a case.”

From personal observation in two cases, I am convinced that the first step
to the formation of a calculus may be the appearance of a cyst in the cortical
substance. In this cyst a calculus is later deposited and it is likely later on
that the cyst may rupture into a calyx in which accordingly the calculus may
come to lie. I do not suggest that this mode of formation is of frequent
occurrence, but unless it is recognized, the chance of overlooking a stone
during operation is increased.

Observation I .—In a case under my care, renal calculi were successfully removed
from An infected left kidney. A second operation for the removal of multiple calculi
from a disorganized right kidney was fatal. The necropsy showed that all calculi had
been removed from the kidney, but in its upper pole, unconnected with the calyces,
was a small cyst containing turbid fluid and lined by a layer of gritty debris. Small
gritty areas could be appreciated by the finger, though they could not be seen, in the
substance of the left kidney.

Observation II .—After the removal of a group of calculi from a kidney by sub¬
capsular pyelotomy, the two smallest calculi, one of them known to be of recent origin
from a comparison between two radiographs of different dates, could not be detected.
A probe was passed from the pelvis into the calyces but it failed to detect them.
Needling of the kidney substance in the suspected region was equally unsuccessful.
A finger cautiously introduced into the renal pelvis also failed to find them. On bidigital
palpation between this finger and a finger laid on the convexity of the kidney slight
indurations not hard enough to suggest a calculus were felt in the suspected regions.
At these two points the cortical region was incised with the point of a knife. Each
incision entered a small smooth-walled cystic cavity containing turbid fluid, within
which lay a small mobile calculus about t in. in diameter ( see fig. 1, A and b).
It is certain that these cavities did not communicate with the pelvis, for it was already
freely open, and there was nothing to suggest their origin from the blocking of calyces.

Mh—S 1 [.January 3, 1923.

Handley: Subcapsular Pyelotomy

One of these two stones was known to be the youngest calculus present in the kidney,
a fact which suggests that the others, after originating in cysts in the same way, had
passed secondarily by ulceration or rupture into the calyces and the pelvis.

Observation III .—In the Museum of the Royal College of Surgeons is a specimen
numbered 3618 (now shown) of a kidney split open, and containing a calculus wedged
in the pelvis. Near the middle of the convexity of the kidney and lying close under its
capsule is an empty cystic cavity, ovoid in form, and measuring 1 in. by i in. in section.

Fig. 1 . —Bilateral renal calculus. Case of Mrs. H. Radiograph by Mr. W. A.
Coldwell of the right kidney. C is a large calculus in the pelvis. A and B are two
small calculi which were found lying in cysts in the renal cortex unconnected with the
calyces. In a radiograph taken eight months earlier only calculi B and C were
present.

This communicates by a narrow, oval opening about tin. by k in. in measurement, with
a long dilated calyx, t in. in diameter, which leads down to the blocked pelvis.

I suggest that the stone formed in the cystic cavity, which ulcerated into the calyx.
The stone then passed into the pelvis and lodged there. The observation is from the
nature of the case a suggestion only, but I believe the specimen represents a third stage
in the history of a cyst-calculus. How otherwise can one explain the existence of a

Section of Surgery 23

globular cystic cavity at the blind end of the calyx, extending right to the surface of the
kidney, and communicating by a constriction with the dilated calyx ?

It is noteworthy in the descriptions of kidneys with renal calculi that the
calyces are often described as extending almost to the surface of the kidney*
even in kidneys the substance of which is not greatly atrophied. I suggest
that in some cases the portion of these supposed enlarged calyces which lies in
the cortex is the original cavity of a cyst in which a stone has formed, and
that the communication with the calyx is secondary (see fig. 2). The normal
calyces end at the apices of the pyramids and do not extend into the cortical
substance.

I have not been able to form any idea as to the frequency with which
a renal calculus originates in a cyst of the cortex, but my observations prove

Fig. 2. Fig. 8.

Fig. 2.—(No. 3631, Path. Series, R.C.S. Museum.) A kidney, in which the pelvis
and aU its branches are dilated into large pouches, over which the glandular
substance is spread out and atrophied. The dilated pelvis and many of the calyces are
full of large calculi.

Note that there is no general atrophy of the renal cortex. It appears likely that
the “large pouches,” in which the calculi lie, and which extend nearly up to the
capsule were formed, not by dilatation of calyces, but as cysts in the renal cortex.

Fig. 3.—(No. 289, Anatomical Series, R.C.S. Museum.) Posterior half of injected
normal kidney looked at from the front.

Note that the splitting of the kidney has failed to open up several of the calyces.

beyond a doubt that a calculus may originate in this way, and I suspect that
this mode of origin is frequent. It is evident that, just as in the case of a
sacculus of the bladder, the little stagnant pool of urine in a urinary cyst of the
kidney supplies conditions very favourable to precipitation.

With these few remarks on the pathogenesis of renal calculi, I now pass to
the more important part of my paper, a consideration of the best method
of removing stones from the kidney.

Handley: Subcapsular Pyelotomy

Nephrolithotomy.

I maintain that the operation of nephrolithotomy, or splitting of the
kidney, is an unscientific procedure to be regarded only as a last resort.
It is an operation sometimes attended by dangerous bleeding and always by
permanent injury to its secreting substance. Moreover, it may fail in its
object of exposing all the calyces, for one or more of them may not lie in the
place of the incision (see fig. 3). It should be reserved for cases of very large
calculus such as one which I removed successfully, which measured 5 in.
in length, and for cases in which the necessary exposure for an incision into the
renal pelvis cannot be effected owing to a short pedicle or a deep loin.
During the last ten years I have only twice been driven by necessity to do a
nephrolithotomy in preference to a pyelolithotomy.

Thomson-Walker in his work on 14 Surgical Diseases and Injuries of the
Genito-Urinary Organs/* adopts, it seems to me, too detached an attitude in
discussing the rival claims of nephro- and pyelolithotomy, and yields too large
a territory to the former operation. But that his real preference is for
pyelolithotomy is shown by his recommendation of this operation in the critical
oases in which a stone has to be removed from a solitary functional kidney.

Cases Suitable for Nephrolithotomy .—Very large calculi, irremovable by
way of the pelvis, can sometimes be extracted by splitting the kidney, without
a nephrectomy. In cases with a short pedicle and a deep loin, pyelolithotomy
may he impossible, and nephrolithotomy quite feasible.

Restricted Nephrolithotomy.

Though 44 splitting the kidney ” in a plane posterior to its mid-coronal
plane has thus a very limited field in present-day surgery, there is something
to be said for what may be called restricted nephrolithotomy. As Hartmann
has insisted, if upon exposure of the kidney a stone can plainly be felt in its
substance and near to its surface, it is best to cut down upon it directly
through the renal substance if the radiograph has shown that the stone is
single, and that therefore further exploration of the kidney is unnecessary.
A small incision only is necessary, little damage to the kidney substance
is done, and the operation has the merit of rapidity, directness and simplicity.
If several calculi are present, and if each of them is to be plainly felt near the
surface, a cut directly down upon each of them may be the best course to
pursue, but only if the operator is certain beyond doubt that he can feel each
of the calculi shown by the radiograph. After limited nephrolithotomy each
of the incisions should be closed by one or more loosely tied catgut sutures.
During the incision of the kidney and the extraction of the stones, the kidney
pedicle should be compressed by the assistant’s fingers.

Bipolar Nephrotomy (Legueu).

In cases in which the stone or stones cannot be palpated externally, some
surgeons recommend that the kidney-pelvis should be reached by two incisions
which follow respectively the upper and the lower thirds of the kidney-splitting
incision, the uppermost and the lowest calyx being opened. In this way
it is said that the whole kidney can be explored. I do not think, however,
that free access to the pelvis can be obtained in this way. The communication
of the upper calyx with the pelvis is often a very harrow and restricted
orifice (fig. 4), and I found in a case of my own that it was useless for reaching
and exploring the pelvis. The same objection applies to the lower calyx,
though to a much less extent.

Section of Surgery

Unipolar Nephrolithotomy.

Albarran recommends an incision into the lower pole, following the lower
third of the convex border of the kidney, as a means of exploring the renal
pelvis. The same objection applies to this operation. It does not open the
main cavity of the pelvis, and affords very restricted access to that cavity.
Though it is true the narrow opening of the calyx into the pelvis may be
enlarged with scissors, it still seems undesirable and clumsy to approach
a branching cavity such as the renal pelvis from the side where it breaks up
into branches. Strategically, it should be approached from the opposite side,
where it is a single simple cavity from which the branches diverge. From
this point and from no other all the branches can be explored with ease.
The plumber seeking a defect in a drainage system opens the manhole into
which the accessory drains converge, and from which they are all accessible.
He does not reach the manhole by splitting up one of the small drains and
enlarging its orifice into the manhole, but opens the manhole directly. For
reasons similar to those which guide the plumber, I believe lower pole

Fig. 4.—(Physiological Series, R.C.S. Museum.) Metallic injection of the chief
veins of the kidney. Pelvis and ureter injected with wax. Prepared by Professor
Wahby, of Cairo, and presented by the Egyptian Government in 1914.

This figure is inserted to show the narrowness of the communication between the
upper calyx A and the body of the renal pelvis B in some kidneys.

nephrotomy to be an unsatisfactory operation, and that, save for the limited
exceptions already made, the kidney should be explored for stone by way
of the renal pelvis, for this cavity bears the same relation to the kidney as
the manhole to the drainage system from the fact that all the accessory
ducts converge to it and can be explored from it; and there is the further
resemblance that the renal pelvis like the manhole can be easily opened and
reclosed without injury to the drainage system.

Pyelotomy.

At the present day there would probably be a consensus of opinion that
stones known to lie in the pelvis should be extracted by pyelotomy. I would
go further and maintain that pyelotomy should be the routine first step in the
operative examination of a kidney for calculus, and that nephrolithotomy
should be regarded only as a last resort.

Handley: Subcapsular Pyelotomy

The Technique of Pyelotomy .—The opening of the renal pelvis is an
operation of comparatively recent introduction. I find for instance that in
the 1904 edition of Cheyne’s and Burghard’s “ Manual of Surgical Treat¬
ment ” the operation is not mentioned. The accepted method of performing
the operation is thus described by Thomson-Walker 1 :—

“ The kidney is drawn out of the lumbar wound. The organ is grasped in the left
hand of the operator and turned forwards and upwards so that the posterior aspect of
the pelvis is exposed. The fat covering the pelvis is removed with dissecting forceps.
A posterior branch of the renal artery lying immediately within the renal sinus and
irregular vessels must be avoided. If a stone is felt in the pelvis it is made prominent
by pressure of the fingers on the front of the pelvis, and a longitudinal incision is made
upon it through the posterior wall. The stone is then removed with forceps.

“ If a stone is not felt, the kidney is given to an assistant to hold, and a longitudinal
incision is made in the pelvis about 4 in. in length, a fine catgut suture passed through
each lip, and the wound held open by these sutures. A probe is now introduced and
the pelvis and calyces are explored. If a calculus is now felt, the probe is held in
position and a pair of forceps slipped along it, the stone grasped and removed.

“After removal of the stone, the edges of the wound in the pelvis are brought
together by interrupted stitches of fine catgut. Over this a row of Lembert’s sutures
may be inserted.

“ Since 1905 I have covered all wounds in the renal pelvis with a flap of the fibrous
capsule turned down from the kidney and stitched in place. This has proved very
successful in preventing the escape of urine and promoting primary healing. Mayo
recommends a flap of fatty tissue for the same purpose.

“A drainage tube is placed behind the kidney and the lumbar wound closed.
Usually there is no escape of urine, but occasionally some urine leaks for a few days.
Rarely this continues for a fortnight or longer, and a urinary fistula may become
established.

“ The cases which are suitable for pyelolithotomy are those of small unbranched
stones lying in the pelvis.”

Some surgeons, notably Hartmann, of Paris, maintain that it is quite
unnecessary to suture the incised pelvis. Hartmann records six cases of
pyelolithotomy, all of them successful. No escape of urine from the wound
occurred in any of these cases. Hartmann states that Mayo, in America, has
also abandoned suture of the pelvis.

There seems to be no doubt that suture of the pelvis is unnecessary. I may
remark that Sir J. Bland-Sutton has found suture of the common bile-duct
after incision also superfluous. The insertion of a double layer of sutures in
the pelvis is a tedious business, which increases the strain of the operation
upon the patient’s vital powers, while it must also tend undesirably to
diminish the size of the pelvis. I cannot help thinking, however, that the
firm, immediate and accurate closure of the pelvis after incision is an end
desirable in itself if it can be attained quickly and simply. For the past ten
years I have employed the method which I will now describe.

Subcapsular Pyelotomy.

The kidney having been exposed by a lumbar incision is brought up to the
surface intact in its capsule. All small bleeding vessels are clamped and tied.
An incision about 3 in. long (fig. 5), and following the long axis of the posterior
surface of the kidney, is now made through the fibrous capsule. It does not
involve the substance of the kidney. Two pairs of forceps are clipped upon

1 “ Surgical Diseases and Injuries of the Genito-urinary Organs,’ 1 1914, p. 273.

Section of Surgery

the posterior edge of the incision in the capsule. While these are steadied, a
pair of dissecting forceps is insinuated beneath the capsule in the direction of
the pelvis until the entrance to the hilum of the kidney is reached (fig. 6).
Here the capsule, or one layer of it, leaves the kidney and passes on to the
posterior surface of the pelvis. The forceps or blunt dissector enlarges the
pocket formed beneath the capsule until at its bottom the line of entrance of
the pelvis into the substance of the kidney is reached. A knife is now taken
and with its point the posterior surface of the pelvis is cautiously incised at
the bottom of the capsular pocket in the long axis of the kidney. Forceps
(fig. 7) or, if necessary, the finger can now be introduced into the pelvis,
stones present in it removed (fig. 8) and its recesses explored.

When the opening in the pelvis has served its purpose it can be completely
and rapidly closed by three stitches uniting the edges of the original incision
in the capsule on the posterior surface of the kidney (fig. 9). No suturing of

Fig. 10. —(Physiological Series. R.C.S. Museum.) Injection with fusible metal of
the arterial system of the kidney, by Professor Wahby, of Cairo. Note the posterior
branch of the renal artery.

the renal pelvis itself is necessary and the duration of the operation is
correspondingly shortened. In the case of an infected kidney, the chances of
infection of the perirenal tissues are much reduced because the flap or pocket
of capsule prevents septic fluid from escaping into them from the incised renal
pelvis. The security against a urinary fistula appears to be absolute.

Complications.

I have performed this operation, supplemented when necessary by cortical
extrusion of stones, in perhaps nine unilateral cases of renal calculus, and in
two bilateral cases. In all the unilateral cases, the calculi were small and lay
in the pelvis or in calyces from which they could be extracted by way of the
pelvis without incision of the kidney substance. In none of the unilateral
cases did any complications worth noting present themselves. In two or three

Handley: Subcapsular Pyelotomy

cases a discharge of slightly urinary odour was present for a few days. In
one case a stone, after extraction, was lost in the perirenal tissues.

There is a theoretical risk in pyelotomy (see fig. 10) of cutting a branch of
the renal artery which passes over the upper edge of the pelvis to reach its

Fig. 11.—(No. 3618 Path. Series, R.C.S.) A kidney the pelvis of which is nearly
filled with a calculus. The pelvis was surrounded by a large quantity of fat F, which
has been dissected away from one side of it.

The calyces are dilated and the substance of the kidney is so much atrophied that
some of the dilated calyces nearly reach its surface. The surface is granulated, and,
in some situations, seamed and drawn in as if cicatrized after ulceration or loss of
substance.

Note that all the branches of the pelvis lie within the cavity of the renal sinus, and
that a subcapsular pyelotomy would open the main pelvic cavity.

posterior surface, but in ten years I have had no trouble from this source. I
believe that reflection of the fibrous capsule in the subcapsular operation must
push this artery out of danger—an additional advantage of the method. I have
avoided carrying the incision in the pelvis right to its upper border, so as to

Section of Surgery

minimize this possible risk. The re-suture of the capsular flap secures efficient
haemostasis of any small vessel in the divided edges of the pelvis.

It might be thought that the operation of pyelotomy would be difficult or
impossible in cases of compound branching pelvis. It will be found, however,
that the branches of such a pelvis lie right within the sinus of the kidney and
that an incision made in the way directed, just in the line of the hilum, enters
the main cavity even of a compound branching pelvis. A specimen from the
Royal College of Surgeons Museum (fig. 11) illustrates this point. I may add
that I have not yet failed to find the cavity of the pelvis when it is incised in
the way described.

The suture of an incision in a compound branching pelvis might well prove
to be impossible without producing a dangerous stricture of its cavity. But if
the subcapsular method of incision be adopted the problem does not arise.

Fig. 12.—(No. 241.2, Physiological Series, R.C.S. Museum.) Kidney with compound
branching pelvis. A human kidney, injected and divided longitudinally to show the
chief points in the structure of the kidney with pelvis of the multiple type.

The ureter dilates a short distance external to the hilum to form a common pelvis
which divides within the 44 sinus” to form two main branches that in turn break up
into minor branches or infundibula each related to one or occasionally to two
mammilla;, through which the uriniferous collecting tubes of a pyramid open.

The blood-vessels pass through the hilum into the sinus and enter the kidney
substance in the interspaces between the infundibula of the pelvis. The fat in which
in nature the vessels are embedded has been removed. The separation of the kidney
into cortex and medulla is clearly marked by the rich arterial supply to the cortex ana
by the radial striation of the medulla due to the direction of the collecting tubes and
the position of the veins between them.

In the kidney represented in fig. 12 it is possible that instead of opening
the main pelvis two separate infundibula might be entered. But their common
attachment to the flap of capsule would ensure the reconstitution of the pelvis
and minimize the risk of a subsequent fistula.

Bidigital Exploration of the Kidney .

In cases in which a probe introduced into the calyces fails to detect a
calculus known to be present, time should not be wasted in needling the kidney.

Handley: Subcapsular Pyelotomy

The incision in the pelvis should be enlarged cautiously to an extent sufficient
to permit the gentle introduction into the pelvis of the gloved forefinger of the
left hand in the case of the right kidney, and vice versa. I am aware that some
surgeons object to the introduction of the finger into a deep wound as vitiating
asepsis. With this objection I can only agree if the word “ unnecessary ” be
inserted before the word “ introduction/* It is unwise to erect a general
principle into a fetish. For certain purposes in surgery the gloved finger gently

Fig. 13.—Bidigital examination of the kidney.

used, and with due precautions as to asepsis, is not only the safest, but the only
instrument which will supply the necessary information, since it is the only
instrument the outer surface of which is in direct connection with the observer’s
brain. When the finger has been insinuated into the pelvis it will go no farther.
The calyces are inaccessible to it. They are, however, not impalpable. If a
finger of the other hand be used to make counter-pressure on the convex surface
of the kidney (fig. 13), it is, I think, most unlikely that any small induration

Section of Surgery

produced by a calculus in a calyx can escape observation. Even if the small
calculus be mobile within a cyst, as in one of my cases, a vague induration will
be felt by this bidigital method and will invite exploration. In the case of a
stone lying in a calyx a gentle impulse given by the internal finger will be felt
by the external finger as a definitely localized “ lift ” imparted to the external
finger over a small and well-defined area of the kidney surface.

FiG. 14.—Extrusion of a renal calculus through a small incision*in the cortex.

Extrusion of Calyx Calculi through the Renal Cortex .

When a stone has been located in a calyx, the finger within the pelvis may
be withdrawn and an attempt may be made to seize the calculus by a forceps
introduced by way of the pelvis. Frequently, however, a constriction between
the calyx and the pelvis will render the attempt unavailing. It is probably
better as a rule not to make the attempt, but to retain the internal finger within
the pelvis. The finger is used to press the calculus gently towards the cortex
and, with the point of a knife, the calculus is cut down upon through the cortex
by an incision hardly longer than the diameter of the calculus. This step is

Handley: Subcapsular Pyelotomy

rendered quite easy by the efficient counter-pressure of the internal finger.
A little extra pressure and the calculus can often be made to protrude on the
surface of the kidney through the small incision, or if this does not happen it
is easy to extract it, fixed as it is by the internal finger, by introducing suitable
forceps into the little incision, which is subsequently closed with a single
catgut suture (fig. 14). Search is then made for other calculi which, if present,
are removed in the same way, each through a separate small incision. The
efficiency of the search which can thus be made is illustrated by the kidney
shown, from which more than a dozen calyx calculi were removed. The
operation was a severe one and the case is the only fatal one of my series.
After death no residual calculi were found in the kidney.

Thomson-Walker states that “ in an exploration of a kidney for a stone
which cannot be felt in the pelvis, pyelotomy ... is looked upon as inferior
to nephrotomy. In a single large pelvis (ampullary pelvis) Legueu looks upon
the two operations as being equally efficient.” If, however, there is a branched
pelvis, Thomson-Walker regards nephrotomy as the better operation. It is
here that I cannot agree with him for the reasons already stated. At the
entrance to the hilpm, the line in which a pyelotomy incision is made, it will
usually be found that even a branching pelvis presents a single cavity which
can be incised sufficiently to admit a finger. The branches of a branched
pelvis lie in the deep concavity of the hilum (fig. 11), and from an operative
point of view are merely elongated calyces. At any rate I have not yet met
with a pelvis which was not amenable to pyelotomy.

I am indeed prepared to admit that in a branched pelvis it might be quite
impossible to extract by way of the pelvis, calyx calculi or even calculi in a
main branch of the pelvis. This, however, I do not regard as an argument for
nephrotomy. The difficulty can be overcome, without risk of haemorrhage or
injury to the kidney, by the adoption of the bidigital method of exploration
and by extruding the stones by means of small multiple incisions in the renal
cortex. This may indeed be called a limited nephrotomy, but in practice
there is the widest difference between this method and the usual splitting
of the kidney.

The most complete splitting of the kidney may fail to hit off the plane of
one or more of the calyces, so that nephrotomy does not really afford so much
security against missing a stone as is given by the bidigital method.

It is usually stated that urinary fistula occurs more frequently after pyelo¬
tomy than after nephrolithotomy, a view endorsed by Thomson-Walker.
Schmieden’s percentage of fistulas after pyelotomy was as high as 22. There
would here appear to be a real advantage in favour of nephrotomy, but I
believe that pyelotomy by the method I have described to-day is never
followed by a urinary fistula. At any rate the complication has not yet
occurred in my experience, and it is on this account as much as by reason of
its simplicity of technique that I venture to commend subcapsular pyelotomy
combined when necessary with bidigital examination and cortical extrusion of
calyx calculi, as the best plan of dealing with most cases of renal calculus.

Case Records .

I append the records of three cases. One of them is chosen as a typical
example of early unilateral renal calculus—the common type. The other two
are cases of bilateral renal calculus already referred to.

Case /.—E. L., female, aged 27, admitted to the Middlesex Hospital under my care
on December 15, 1914.

Section of Surgery

History : She had complained of an intermittent gnawfhg pain in the right side for
two years. An appendectomy had been done without benefit. The pain was worse
after exertion, but eased by lying down. Since September, 1914, when she had a
severe attack of pain and felt sick, the urine had been much darker. Similar attacks
have since recurred twice or three times a week.

On admission the temperature was normal, and the urine free from blood and
albumin. The kidneys could not be felt.

Operation: On December 31 the kidney was exposed by a lumbar incision and
delivered. The pelvis was opened by subcapsular pyelotomy and a rough stone the size
of a large pea was removed from it with a spoon. The capsule was sutured, the kidney
returned, and the wound closed. Six days later the urine still contained much blood
and albumin. The following day the drainage tube was removed. No urinary discharge
had occurred. On the thirteenth day there was no blood in the urine and the patient
left the hospital on the twenty-sixth day with the wound soundly healed.

Case II. —Patient, a male, C. L., aged 27, admitted to the Middlesex Hospital under
my care on November 17, 1922.

History: About fifteen years previously this patient had a calculus removed from
the right kidney. Five months before being admitted to hospital, he had pain in the
back on the left side, and noticed that his urine had a reddish tinge. Pain has been
continuous, but patient has been able to do his work. The pain is less when he lies
down. On Qctober 2 the pain became acute, he vomited the following morning, and
the attack passed off. Another attack began on October 10, and lasted until October 14,
preventing him from doing his work. On October 15 pain came on again, and has been
continuous ever since. The pain has always been in the back, and has never radiated
down the thigh or to the testicle.

Condition on admission: Temperature 102*2° F., pulse 112,respiration 24. Patient
looks ill, and complains of pain in the loin on the left side. On palpation the kidneys
cannot be made out, but there is tenderness on the left side below the twelfth rib, and
external to the erector spin® muscle. There is slight tenderness on the right side in the
same region. Urine 1012, acid, contains albumin and blood.

X-ray report: Group of large calculi in right kidney. Two calculi present in left
kidney.

Blood urea test report: “ Blood urea, 54*0 mg.; protein nitrogen, 53*76 mg. These
are dangerously high figures.”

Bacteriological report: “ Many pus cells. Streptococci or coliform bacilli seen in
direct films and grown in cultures.”

The acute symptoms slowly subsided with rest in bed, and his temperature became
normal.

October 28, 1922: Patient has been sitting up for one to two hours each evening
since October 24, and the excretion of urine has gone up from 48 to 76 oz. Was given
boric acid 10 gr. t.d.s. from October 24.

October 30, 1922 : Blood urea, 28 mg.; non-protein N., 36*5 mg. (normal figures);
temperature, normal; pulse 68*72.

November 7 : Staphylococcus aureus vaccine No. 1, *1 minim given.

November 9 : Staphylococcus aureus vaccine No. 1, 1 minim given.

November 11: Staphylococcus aureus vaccine No. 1, 2 minims given.

November 18, 1922, operation by Mr. Handley: Lumbar incision on the left side.
The kidney was delivered partially and with great difficulty; it was found to be greatly
enlarged, having a short pedicle and its surface showed lobulation. The capsule was
incised in the posterior surface near the pelvis, but it was not found possible to do a
subcapsular pyelotomy on account of the shortness of the pedicle and the elongation
of the patient’s thorax. The two stones which could easily be felt in the lower pole
were therefore extracted by direct incision of the renal cortex over them ; one was the
size of a small plum and one the size of a cherry. The opening in the kidney
substance was closed with capsule sutures and the capsule w r as closed. The kidney
was then replaced in the abdomen and vaseline gauze packed round the incision
in it (on account of tendency to ooze). Wound closed with catgut sutures. A

36 Handley : Subcapsular Pyelotomy

drainage tube was left in. 1 * The end of the vaseline gauze protruded through the
incision.

November 14: Blood-stained discharge on gauze dressing this morning; drainage
tube shortened and about 8 in. of vaseline gauze removed.

November 15: Remainder of vaseline gauze removed this morning. Blood¬
stained discharge on dressing. No leakage of urine since ; no effervescence is obtained
on pouring a solution of sodium hypobromite upon the dressing.

November 16: Dressing soaked with fluid of ammoniacal odour.

November 20: Dressing still soaked with urine. Dressing changed and dry dressing
applied.

November 22 : Stitches removed. Tube shortened.

November 28 : Eusol dressing. Discharge slightly purulent.

November 29: Flavine dressing. Very little discharge and patient getting
stronger.

December 7 : Some fluid discharged from wound, not smelling of urine. A few
days later the wound was healed completely, and the patient rapidly recovered his
strength.

December 18: Prepared for operation. Temperature normal in the mornings,
rising to 99° F. at night. Pulse 84 as a rule.

December 18, operation by Mr. Handley : Patient was placed on the left side and an
incision was made in the right loin. The kidney was exposed and numerous capsular
adhesions found and divided. The kidney was withdrawn. One stone could be felt
close to its surface at the upper pole and was removed through the cortex, an opening
over it being made with Spencer Wells forceps. It was about the size of a walnut.
Another stone could be felt through the same opening and was removed in like manner :
it was larger than the first. The pelvis of the kidney was now opened under cover of
the capsule, and five stones were removed with forceps through this opening. Four
other stones were found at the lower pole of the kidney and were removed through the
cortex, one finger of the surgeon being in the pelvis of the kidney to push the stone
towards the surface. The kidney was irrigated with flavine through the cortical wounds.
After this several small stones were removed, and finally one blocking the entrance to
the ureter. The cortical incisions were sutured to control the very considerable
amount of haemorrhage that occurred. Wound sutured with catgut and dressings
applied.

Patient was returned to bed in fair condition, showing signs of shock. He continued
fairly well, but at 8.20 a.m. of the following day he collapsed suddenly, and died. No
evidence of external bleeding on the dressings.

Post-mortem : Small amount of blood round right kidney, not sufficient in itself to
account for death. No residual stones were found in the kidney. Cerebro-spinal fluid
gave no evidence of uraemia. Death was probably due to cardiac failure.

It would have been wiser, I think, to send this patient home for three months before
doing the second operation.

Mr. E. C. Dodds, who kindly analysed the calculi, reported that they were composed
of calcium oxalate and urate, with an outer coating of sodium phosphate.

Case III .—Mrs. H., a delicate woman, aged about 40, was sent to me by Dr. Joseph
White, of Clapham, in July, 1921. In October, 1914, she had an attack of cystitis, and
in March, 1915, blood for the first time appeared in the urine. For a fortnight in
October, 1917, she had pain in the left kidney. In June, 1921, she noticed haematuria
without any other symptoms. The urine was smoky rather than bright, and she did
not consult a doctor. In July, 1921, she again had pain in the left kidney, with frequent
micturition and htematuria. The following day she had a temperature of 100° F. and
vomiting. She was slightly delirious and complained of headache. On pelvic exami¬
nation the left ovary was found to be enlarged and very tender, but this swelling may
have been connected with the ureter. There was much blood in the urine, and the pain
of the day before was now relieved. The signs pointed to a stone in the left ureter now
passed into the bladder. There was undue resistance and fullness in the left loin, but

Section of Surgery

the kidney could not be felt. There was some increased resistance of the left anterior
abdominal wall, but none of the muscles in the left loin. A skiagram of both kidneys
and the pelvis was advised. The X-ray photographs, taken by Mr. Coldwell on
September 16, 1921, showed a large calculus in the left kidney lying low down close
to the ilium. In the left ureter, just below the sacro-iliac joint, there appeared to be
a small calculus. In the right kidney there were two calculi—one large, and a small
one lower down.

It was decided to operate on October 21, 1921, upon the left kidney first. The
kidney was much enlarged. It was cut down upon in the loin, and the pelvis was
opened by the subcapsular method. A large stone, firmly adherent to the kidney sub¬
stance, was abstracted from the lower end of the pelvis. The skin incision was now
prolonged downwards and inwards, and search was made for the stone in the ureter
below the rim of the pelvis, but it could not be found.

It appears likely that the ureteric calculus had passed five days previously to the
operation, on the day when a second skiagram was taken, which showed the ureteric
calculus still in the ureter. On that day, on returning home, the patient became
“ frightfully ill 11 with sickness and pain in the lower iliac region at 4 p.m., and at

7 p.m. the pain suddenly disappeared. These facts were only elicited after the

operation.

When the operation was over there was no escape of urine from the lumbar
wound, although a urinary smell could be detected on the first day. There was some
pyrexia reaching to 102° F. on the third and fourth nights, but this subsequently

subsided. Slight hsematuria on the first day only. The wound healed without

suppuration, and the pain was relieved. On October 5 the left kidney was decidedly
smaller, and the patient’s condition was very satisfactory.

In September, 1922, it was decided to operate upon the right kidney. An incision
was made from the angle between the twelfth rib and the erector spinae downwards and
forwards towards the anterior superior spine. The kidney was brought to the surface,
and the posterior surface of the capsule was incised for about 3 in. near the convex
border of the kidney, and the pelvis was opened with the point of a scalpel cautiously
introduced beneath the capsule flap. The opening was then enlarged with a pair of
forceps until a curved pair of forceps could be introduced, which easily gripped a large
stone free in the pelvis. A sound was then introduced into the calyces in all directions
but failed to find any sign of another stone. No induration could be felt ifi the kidney
substance on palpation. A gloved finger was now carefully introduced into the pelvis,
but still no stone could be felt. However, upon bimanual palpation between the finger
in the pelvis and an external finger, two areas of slight induration corresponding to
the two small stones in the radiograph (fig. 1) could be detected in the substance of
the kidney. Short incisions about an inch long, through the kidney substance at its
convex border, entered a cystic cavity at both points where induration was felt.
Slightly turbid fluid escaped from the cysts, which were evidently not in communica¬
tion with the pelvis of the kidney. Two small calculi were found severally free in the
interior of each cyst. The upper calculus was of recent origin, for it was not shown
in the skiagram of the right kidney taken eight months before the operation. The
kidney substance was sewn up, the capsular flap was replaced in position and fixed by
two or three stitches, a small drainage tube was introduced, and the skin incision
sutured. No urinary discharge occurred during convalescence. A little pyrexia
was present for a few days, and subsequently the patient made an uninterrupted
recovery.

In July, 1922, the patient’s husband reported that she was “ marvellously well.”

Mh- S 2 *

Handley: ,Subcapsular Pyelotomy

DISCUSSION.

Mr. Frank Kidd said that the question of the pathology and technique of the
removal of stones from the kidney was one of great complexity and difficulty, so that
only the fringe of the subject could be touched upon at a discussion like this. For
instance, an infected kidney gave rise to stones of a peculiar character and had then to
be approached and treated in a very different manner to a stone-containing kidney
which was not infected; and again, wisdom might dictate a nephrectomy rather than a
nephrolithotomy in difficult unilateral cases and might not only be an operation
attended with less risks, but might also ensure freedom from recurrence.

Confining his remarks to the question of stones lying in a non-infected kidney he
emphasized the point that complete splitting open of the kidney as at a post-mortem
examination was a highly dangerous procedure and one that should seldom, if ever, be
carried out. If a stone was so large and branched as to necessitate the splitting of the
whole kidney it often meant that nephrectomy was preferable to nephrolithotomy,
nephrectomy being a less dangerous procedure and ensuring freedom from relapse.
What was the danger of splitting the kidney? It was haemorrhage. Immediate
haemorrhage from the slitting of large arteries might be so severe that it could not be
controlled, with the result that the kidney had to be sacrificed straight away. On the
other hand, it might be possible to control the bleeding by catgut stitches and yet on
the eighth to the tenth day the kidney digested these stitches and severe secondary
haemorrhage occurred, for which nephrectomy in a hurry was the only remedy if life
was to be saved. He had had only one such case in his own practice—a patient with
a very septic kidney operated on in a military hospital under poor conditions—for he
had hardly ever needed to split the kidney, and indeed had carefully avoided doing so
as he knew the dangers. But he had noticed in hospital records that quite a number
of cases of secondary haemorrhage occurred, following nephrolithotomy, at the general
hospitals. He had pointed out the dangers of splitting the kidney in an article he
wrote for Treves’s “ Surgery,” giving diagrams of the arrangement of the blood¬
vessels. Nevertheless this did not mean that pyelolithotomy should be adopted as a
routine procedure. It also had its dangers of haemorrhage, as he would show 7 . Wher¬
ever possible one should endeavour to make an incision through the pelvis and remove
a stone or stones through that incision as it was the safest and simplest method of
extracting stones of moderate size from the kidney, but one should not make an
exclusive practice of this procedure. If there was a single nose-stone lying in the
pelvis itself this should be lifted out at once without chipping bits off. The opening
in the pelvis should be explored by the gloved little finger, which was better than any
probe, and the whole kidney and every calyx palpated in turn bimanually. If further
stones were known to be present and were detected gripped in the neck of a calyx it
would be found in nearly every case that the cortex was thinned out into a cyst super¬
ficially to these stones, in other words a local hydronephrosis of a single calyx. For
many years he had taught that knowledge of this fact of the thinning of the cortex
over a stone in a calyx was the key to successful and conservative stone surgery. It
was a very simple matter to make a small incision through the thin cortex when a
dimple could be felt over each stone and to pull out each stone through this. The
incision need not be more than half an inch long, so that there would be no serious
bleeding. Each wound was stitched up with catgut and neither leaked urine nor gave
rise to secondary haemorrhage. This procedure was far less dangerous than to attempt
to drag a stone through the narrow neck of a calyx. Large arteries and veins usually
surrounded the necks of calyces, and by the dragging of a stone through the narrow
neck these vessels became liable to be tom, and bits of stone w T ere also chipped off and
left behind. By thus combining pyelotomy with small incisions over individual stones
through the thinned cortex it was usually possible to avoid gross splitting open of the
kidney.

If it was decided the kidney should not be sacrificed and yet that it should be split
to get out a large branched stone, in the first place the pedicle should be temporarily
controlled, and in the second place an incision should be made through the 44 bloodless

Section of Surgery

line ” of Brodel which he (Mr. Kidd) had described in Treves’s “ Surgery,” and not
through the outer border of the kidney as performed in the post-mortem room. The
stone should be grasped with the greatest gentleness so as to avoid fragments being
left behind. If bits of stone were chipped off the kidney should be thoroughly washed
out with several pints of lotion until the operator was satisfied that no chips were left
behind. In all cases a bougie should be passed down the ureter as far as the bladder.

Every case of stone in the kidney or kidneys should be made a study in itself. It
was not possible to lay down universal rules. Judgment and experience were the keys
to success. X-ray pictures should be taken at several days’ intervals on at least two
occasions in every case. No case should ever be operated on after one X-ray examina¬
tion only, nor should any case be operated on simply because the X-rays showed up a
stone. Adequate indications such as undue pain or evidence of renal damage must be
present to warrant an operation. With good X-ray pictures it was usually possible to
map out the number and position of all the stones present and to make up one’s mind
as to the type of operation likely to be required. The final decision however should
not be made until the kidney had been exposed and was in the hand of the operator.
It was always advisable to get the kidney right out on to the loin before exploring it
for stone, as in this position it could be better explored, and haemorrhage, if it arose,
could be better controlled. This was more often possible through the type of posterior
incision he (Mr. Kidd) employed than through the lateral incision usually adopted in
this country. The technique of the operation was then decided upon after a combined
study of the X-ray plates and of the kidney in hand.

He (Mr. Kidd) had lately returned from America, where he had had the opportunity
of seeing the Mayos at work. Off and on for many years kidney operators had endea¬
voured to apply X-rays by means of the fluorescent screen to kidneys at operation, but
so far with little success. He (Mr. Kidd) was interested to see that the Mayos
were now employing a new type of machine with a small Coolidge tube by means of
which they were able to screen the kidney exposed at operation. The experience of
the Mayos had been that a great many stones were left behind in the kidney. They
stated that if the kidney was cleared of stones completely relapse was not likely.
They showed one kidney which was supposed to have been cleared of stones, but the
X-ray investigator maintained that a small stone was still present. The kidney was
eventually taken out and was opened up by a pathologist, who stated that he could
not find any stone. The kidney was X-rayed again and the radiographer stated the
stone was still present. The kidney was then sliced up into small pieces and the stone
was found. The experience just recorded showed the difficulty of making sure at
operation that all stones had been removed and he thought that very shortly it would
be necessary to employ an X-ray apparatus at any operation for stone in the kidney.
As yet the apparatus was rather dangerous to the operator, but it was being perfected,
and he (Mr. Kidd) hoped to make use of it shortly.

The risk of fistula after pyelotomy was a bugbear based on the experiences of the
early operators. Personally, he had never seen such a complication, and he had carried
out more than one hundred pyelotomies. Fistula could only occur if little pieces of
stone were chipped off and left behind, preventing natural drainage of urine from the
stitched pelvis. There need, therefore, be no fear of doing a pyelotomy because of the
risk of a fistula.

During the last year he had operated on four cases of bilateral renal calculi and in
each case he had done both kidneys at one sitting. It always seemed to him very bard
on patients with bilateral calculi that they should have to undergo two operations.
In the first place a large number of cases with bilateral calculi did not need any
operation at all. Cases of bilateral calculi should not be operated on simply because
the X-ray pictures showed stones, they should only be operated on if they had urgent
or dangerous symptoms. If he considered operation necessary he preferred to operate
on both kidneys at one sitting. He found he could deal with both kidneys in about an
hour and twenty minutes, the patient lying on the face so that there was no need to
move him between the two operations. In cases in which he had done this the patients,
had had no more shock than after an ordinary operation and had done extremely well.

Handley: Subcapsular Pyelotomy

Surgeons should not undertake to operate on stones in the kidney unless they had
made a special study of the minute anatomy of the pelvis and calyces of the kidney,
and the relation to them of the arteries and veins. A good knowledge was also
necessary of the numerous common types of abnormality of these structures.

Finally, he would warn them against being too ready to adopt Mr. Sampson
Handley’s line of incision in pyelotomy. He understood Mr. Sampson Handley had
only carried out this particular operation in about nine or ten cases. If he were to do
it in one hundred consecutive cases in quite a number he would strike a large aberrant
artery which ran down from the renal artery posteriorly to the pelvis. Very often it
would be just under the kidney substance in the hilum of the kidney. It was not
always an easy matter to correct a wound of this artery, and the necessary ligatures
cut off the blood supply of a large area of kidney substance. For that reason he
thought that the line of incision Mr. Sampson Handley recommended should not be
widely adopted. It was much safer to make an incision from the ureter longitudinally
upwards, and then, if desired to enlarge the incision, to carry it outwards and down¬
wards into the kidney substance for a short way so as to avoid the artery he had
mentioned. In that way quite a large opening could be made. Incisions in the renal
pelvis should always be sutured, if possible. It only took a few minutes to suture
them and then cover them with a flap of fat; nevertheless, if inexperienced operators
found difficulty or need arose for rapid closing of the wound then it was safe to leave
them unsutured; but the wounds took longer to heal up and were more liable to septic
complications. He always expected to get first-intention healing without any leak of
urine at any time from his pyelotomy wounds. Nevertheless it was a wise precaution
to leave a small drain in the wound for a few days.

Mr. J. Swift Joly said that he endeavoured in each case to select the operation
which would do least damage to the kidney. No rigid rule could be prescribed as to
the relative merits of nephrolithotomy and pyelolithotomy. Much depended, to begin
with, upon the patient’s physique. In a fat person, with a thick abdominal wall, the
kidney perhaps could not be got sufficiently out of the loin to enable pyelolithotomy to be
done with safety. Again, the relative size of the stone to the area of the renal pelvis
was a factor to be taken into account. If a stone was definitely in the renal pelvis not
extending up into the calyces a pyelolithotomy could almost always be done, providing
the kidney could be brought out of the loin. There was no real limit to the size of the
true pelvic stone which could be got out through the pelvis. Recently he had removed
two stones from a kidney pelvis through a pelvic incision, the larger stone being about
the size of a hen’s egg and the smaller about the size of a cherry; but the patient had
a dilated pelvis, and it was easy to get them out. But when, owing to branching, the
stone involved calyx as well as pelvis it was not always possible to get it out through
the pelvis, and to attempt that operation was to do more damage to the kidney than
would be done by making a clean cut through the kidney itself. When there were
stones both in the pelvis and in the calyces the line of conduct would be governed
chiefly by the amount of dilatation of the pelvic-calyx system. If the kidney was dilated
and the pelvis and all the calyces were dilated, these stones could be got out through
the pelvis quite comfortably; but if, as often happened, though the pelvis was dilated,
there was a very narrow opening between pelvis and dilated calyces, he thought it
wrong to try to enlarge that opening either by dilatation or by cutting through the pelvis.
It was much safer to cut through the cortex in such cases, and while taking the pelvic
stone out through the renal pelvis to take the smaller stones out by way of the cortex.
He went on to consider the methods of exploring the kidney in those uncertain cases in
which the X-rays showed a small shadow, whose exact position was uncertain, and
nothing was very palpable. Generally the X-rays gave a good idea of the locality of
the stone, and this greatly simplified the operative technique. But if quite in the dark
as to where the stone was the rule he followed was first to look at the renal pelvis.
With a big pelvis, extending well out from the kidney, he opened it and passed in his
little finger and explored the calyces one by one. If he could find nothing there he
made an incision over the lower third of the kidney and cut down on the lower calyx.

Section of Surgery

One was given a much more direct line of action from the cortex downwards than from
the pelvis upwards. This plan of exploration could be continued, but it was rarely
necessary nowadays, for usually the surgeon was able to have a map of the position
before he started.

Mr. R. H. JOCELYN Swan said that it was usttally taught that renal calculi were
only formed in the renal calyces, but he had shown a case and operated upon it before
a meeting of the Section of Urology in which a calculus was firmly embedded in the
cortical substance of the kidney. This case was also of interest from the position
of the calculus in the radiograms ; in the antero-posterior view the shadow seemed to be
too lateral to be in the kidney and suggested a gall-stone, but in the radiograph taken
in the lateral plane, the shadow was opposite the neural arches of the vertebra and not
opposite the centre of the vertebral bodies as was usual with renal stones.

With regard to the operation to be performed for renal stone, he thought that each
individual case must be separately considered. He much preferred to extract a stone
through an incision in the posterior wall of the pelvis if this were possible rather than
through any incision in the renal substance, and it was surprising how large a stone
could be removed in this w’ay. In some cases he had enlarged the incision upwards,
actually incising the margin of kidney overhanging the pelvis, any bleeding being easily
controlled by suture. In some cases in stout patients or with very large or branched
calculi direct incision had to be made in the renal cortex, or again when a second
operation had to be performed for stone on a kidney previously operated upon. Most
cases were obvious when the kidney was exposed, when the best means of approach to
the stone could be determined, but he would always attempt a pyelolithotomy if the
conditions permitted. He had experienced difficulty with small calculi in a long calyx ;
in these cases he advised that an opening should be made in the pelvis and the little
finger introduced to feel the stone. Pressure could then be made on the latter towards
the renal surface, when, the calculus being maintained in position with the finger in the
pelvis, it could be easily removed by a very small incision in the renal tissue.

As stated by another speaker he had a dread of secondary haemorrhage occurring
after a nephrotomy incision and had had on more than one occasion to remove the
kidney as a life-saving measure for severe haemorrhage after this operation. In one
case under a colleague, severe haemorrhage had occurred after a nephrolithotomy
and upon the evacuation of the clot from the bladder a catgut suture used in sewing
the renal cortex came away. He thought that Mr. Handley’s operation was ingenious,
but it would be applicable only in those cases in which pyelolithotomy could be done or
where the posterior surfaice of the kidney could be freely exposed. He w’as sorry
to think that Mr. Handley had recommended it as a safeguard against fistula resulting
from a pyelolithotomy, as in his (Mr. Swan’s) experience this was rare, in fact in his
own series of cases he had not seen it. He did not think it even necessary to do the
elaborate suture of the renal pelvis or to turn the fascial covering over the incision as he
was advised by Sir John Thomson-Walker, but he was content with a few sutures
or even one fine suture to approximate the edges of the incision in the pelvis. He had
more than once left the incision unsutured, after ureterolithotomy for instance, without
any fistula resulting.

Professor HOBDAY stated that calculi of the urinary tract were of comparatively
common occurrence in animals, and although found in all varieties were especially met
with by the veterinary practitioner in the long-lived species such as the horse and
the dog. They were, however, occasionally met with in the sheep, the cow, and the pig,
but generally found by the meat inspector in the slaughter-house. In the horse
he had met with instances in which the calculus had been of such a size that nothing
but the capsule of the kidney was left, and he illustrated jagged shapes which some of
these calculi took by showing on the screen, by means of the epidiascope, several
sketches taken from actual specimens in the kidney of the dog.

Mr. HANDLEY (in reply) said he was pleased to find that a large measure of agree¬
ment existed as to the superiority of pyelotomy over pyelolithotomy save in exceptional

Handley: Subcapsular Pyelotomy

cases. He hoped that Mr. Frank Kidd would give a trial to the subcapsular method,
for the danger of wounding the posterior branch of the renal artery appeared to be a
theoretical one. He believed that during the elevation of the capsule this arterial
branch was pushed out of danger with the capsule. Mr. Swift Joly’s remarks con¬
firmed him in the view that it was usually best to extrude calyx calculi through the
cortex with a finger in the pelvis, rather than to attempt their extraction through the
pelvis. He was very interested in Mr. Jocelyn Swan’s case, in which a calculus was
found imbedded in the cortex. Evidently a calculus might originate in the cortex in
at least two ways, either in its solid substance or in a cyst. Professor Hobday stated
that calculi were more frequent in long-lived animals. If so, they should be common
in the crocodile; he (Mr. Handley) understood that this reptile might live for one
himdred and fifty years.

Section of Singers.

President—Mr. James Berry, F.R.C.S.

A Case in which an Adenoma weighing 2 lb. 3 oz. was
successfully removed from the Liver: with Remarks
on the Subject of Partial Hepatectomy.

By G. Grey Turner, M.S. (Newcastle-upon-Tyne).

The title of this note, for which I alone am responsible, is not sufficiently
explicit. A statement of the weight of the tumour does not suggest the
principal feature of the case. It ought to have been made clear., that the
tumour was sessile, and could only be removed by incisions carried far into
the substance of the liver and that it had unusual pathological features. Even
the weight is by no means a record. Peck 1 recently recorded a case of
angioma which he removed, weighing 3 lb. 14 oz., and refers to one'operated
upon by Pfannenstiel and reported by Langer, in which the collapsed tumour
weighed 5 lb., and was estimated to have been twice that weight when
occupied by blood.

My patient was a boy, I. A. (Reg. No. 18496), aged 13, the only child of
middle-aged parents and somewhat precocious. He was referred to me by
Dr. Christian Kapp, of Gateshead, and admitted to the Newcastle-upon-Tyne
Royal Victoria Infirmary under my care on February 26, 1921, complaining of a
lump in the right side of the abdomen. This was first noticed after an attack of pain
which had come on suddenly whilst doing his homework ten days previously. Up till
this time, he had never suffered from abdominal pain and had enjoyed good health,
playing cricket and football, and taking part in the school gymnasium. The pain was
at first very severe and “doubled him up,” so much so that when he walked, he had
to bend forward to ease it. There was no vomiting. The severity of the pain
diminished during the same evening and he w^as able to sleep, but it was present
more or less until four days before coming into hospital when it went away gradually
so that he was free from pain on admission. His appetite had not been impaired
during his illness, and the bowels had been regular, there being no alteration in the
colour of his stools. There was no difficulty with his “ water,” he had never noticed
blood in it, and only on one occasion had it been cloudy.

Condition on admission: The patient stated that he felt quite well, but had been
told that a tumour was present. He was a normal looking boy with dark hair, pale
face, and sallow complexion, and of about 5 st. in weight. The temperature was 98° F.
and the pulse-rate 80 per minute. The respiratory and cardiovascular systems were
normal. The urine was acid, contained a trace of albumin, and showed a deposit of
urates and phosphates. On examination a large lobulated mass could be seen and
was readily palpated on the right side of the abdomen, just below the costal margin

Jk—S 1

Surg ., Gyn. and Ob fit., September, 1921.

[February 7, 1923.

44 Grey Turner: Adenoma removed from the Liver

and extending almost to the middle line in front and as low as the level of the
umbilicus. On bimanual examination, the mass appeared to extend from the right
kidney behind to the abdominal wall in front, and could be moved slightly antero-
posteriorly in a “to and fro” manner. On percussion, there was dullness over this mass
continuous with that of the liver above and of the kidney behind. There was no
tenderness, no other tumours were discovered, ascites was absent and there was
no evidence of dissemination. Neither cystoscopic examination nor X-ray were
employed.

The symptoms, physical signs and negative evidence led to the diagnosis of a
rapidly growing unilateral renal sarcoma—a condition which is recognized as occurring
in young subjects with but few symptoms and signs beyond the presence of a mass.

An exploratory operation was decided upon, and this was performed on March 1,
1921. General anaesthesia was induced by chloroform, and maintained with “open
ether.”

A vertical incision was made through the outer third of the right rectus abdominis
muscle, extending from the costal margin to about an inch below the level of the
umbilicus. On opening the peritoneum, a large lobulated tumour was at once seen
apparently arising from the right lobe of the liver. It was a matter of remark that
there was no ascites. The tumour was covered by the omentum which was adherent
all over its anterior surface and to the parietes. These adhesions carried some
enormous vessels, and in order to make fuller investigation, it was necessary
to ligature and divide them. This enabled the mass to be partially delivered from
the wound. It was then found to consist of a large tumour occupying almost one
half of the right lobe of the liver. The left extremity of the tumour reached as
far as the notch for the gall-bladder, but this viscus was not involved. The remainder
of the organ appeared to be normal, and nothing suggestive of a primary growth
would be found in the abdominal cavity, so that the condition was regarded as
being of a purely local nature.

The mass appeared to be too limited to one region of the liver to be merely
a cirrhotic change, it had not the appearances suggestive of a gumma, and in the
absence of a primary growth, and considering the age of the patient, it was thought
to be possibly of a simple nature. While the matter was under consideration the
report arrived on a frozen section which had been quickly made from a small portion
of the mass removed earlier in the operation ; this stated that it was an unusual type
of tumour composed of liver cells and probably not of a very malignant nature. On
these grounds it was decided to attempt its removal.

A critical examination showed that this could be carried out by a V-shaped
resection, with the apex just opposite the commencement of the cystic duct,
but without encroaching on the hilus. The gall-bladder had to be removed with
the tumour and the isolation arid ligature of the cystic duct and vessels was first
carried out. The affected portion of the liver was drawn out of the incision as far as
possible, and the stomach and colon were well packed away with large gauze pads.

A light, bow-shaped stomach clamp with jaws 4 in. long, such as I use for gastro¬
enterostomy, was applied on the tumour side of the proposed incision and was slowly
tightened until it had a firm hold. This provided a convenient handle and helped
materially in the subsequent manipulations. With a large fully curved intestinal
needle threaded with No. 8 chromic catgut, a series of sutures were then introduced
into the liver substance on the proximal side of the proposed incision and parallel to
it. These sutures were passed as deeply as possible into the liver tissue and almost
reached the under surface. Four were required: each was locked to its fellow and
they were all separately tied. The liver substance was then gradually incised between
the line of sutures and the clamp. A sharp knife aided by scissors was used, there
was some haemorrhage, but it was not alarming.

Branches of the hepatic artery were recognized either before or just at their
division, by the fibrous capsule accompanying them. Three or four of these branches
were caught in ordinary artery forceps and were subsequently ligatured with fine
catgut. Some venous oozing from portions of the liver which had escaped the
haemostatic sutures was easily controlled by the pressure of a gauze swab. An

Section of Surgery

exactly similar proceeding was carried out on the right side of the tumour, but there
was not so much tissue to be divided, that side of the V not being quite so long.
After the incisions were made, the parts fell asunder, and left a very large formidable
looking gaping wound. It was found that the sides of this gap could be easily
approximated, and it was closed by a series of four catgut sutures passed with the
same needle on the proximal side of the haemostatic sutures which had been first

Fig. 1.—The portion of liver containing the tumour excised in the case of J. A. The
whole weighed 2 lb. 3 oz. Remains of omental adhesions are well shown.

introduced. This brought the surfaces well together, but a few additional interrupted
sutures were required for the exact approximation of the edges.

After the completion of the suturing, there was still some oozing from the under
surface of the posterior part of the liver wound. This might have been controlled by
further stitches but it was thought wiser not to prolong the operation, and therefore

46 Grey Turner: Adenoma removed from the Liver

gauze was packed over the area and was protected from contact with the hollow
viscera by a strand of rubber tissue. A small tube was brought from the stump of the
cystic duct as is my routine in cholecystectomy.

It is difficult for me to give a word picture of all that happens at an operation of
this sort. The conditions are highly unusual, and experience is lacking as to the
effect of such a proceeding on the patient, and there is naturally rather an artificial
atmosphere of apprehension and excitement. I had one assistant, a student house
surgeon (Mr. George Mason who is present this evening) to whom I was accustomed,
and in whom I had complete confidence, but my own anesthetist was unable to be
present.

The operation lasted about an hour and a half, and in the aggregate there must
have been a considerable blood loss. Towards the end of the operation, the blood -
pressure had fallen considerably, and there were other evidences of grave shock which
caused us anxiety. It was therefore considered wise to introduce 10 oz. of gum saline
solution (Bayliss) into the veins, and this was followed by considerable improvement.
While the infusion was being carried out, the abdomen was closed with a continuous
catgut suture for the peritoneum and through-and-through silkworm sutures passed
figure of eight fashion for the other layers. The patient left the table in quite good
condition. Six hours later, the gum solution was repeated.

After the initial shock was overcome, recovery was uneventful except for the
occurrence of a little sepsis along the track of the gauze, which cleared up after the
removal of the latter on the fourth day.

The patient left the hospital twenty-four days after the operation in good condition
and with the wound healed except for a small granulating area at the drainage tract.
He seemingly suffered very little from the removal of such a large portion of an
important organ.

Pathological .—The specimen is preserved in the Museum of the University of
Durham College of Medicine, and the photograph was kindly made for me by Mr.
H. B. L. Dixon. The part removed (fig. 1) was mainly composed of tumour growth
but included a narrow strip of liver tissue covering the posterior and left lateral
surfaces of the growth and the gall-bladder. The whole weighed 21b. 3 oz. (35 oz.),
(the normal weight of the liver in the adult is from 50 to 60 oz. and in a boy aged 13,
about 40 oz). The surface of the growth is lobulated and irregular as the result of
deep branching furrows which traverse its surface. The lower half is also covered
with the remains of adherent omentum. There is no definite capsule and the tumour
appears to be directly invading the liver substance, though the line of demarcation is
plainly seen. The predominant colour is a pale yellowish green, but there are areas of
haemorrhagic staining here and there.

The tumour has been very carefully examined by Dr. A. F. Bernard Shaw of the
Pathological Department of the University of Durham College of Medicine, and a
detailed account of his investigations will be published in the next issue of the
Journal of Pathology . A summary of the microscopic characteristics is as follows:
“ The appearances here are those of a true liver-cell tumour of unusual type. While
the tumour cells are obviously of hepatic origin, they are atypical in structure and
arrangement. There is evidence of both direct and mitotic division and multi-
nucleated forms are seen. Though the tumour cells are actively secreting bile, no
bile-ducts are found in the substance of the growth. No evidence of tumour cell
emboli were seen either in the vessels in the growth nor in those of the adjoining liver
tissue. Sections of the lymph gland, obtained from near the gall-bladder, show’ no
metastases. On the whole the appearances point to an unusual type of hepatic
adenoma in which however the cells are more aberrant than it is usual to find in an
adenoma of simple type.”

The draw ing of the microscopic appearances (fig. 2) was mode from a section at the
junction of tumour and normal liver tissue.

The boy returned on October 28, 1921, for examination, and stated that 44 he had
never felt so w’ell before,” and was now’ regularly attending school, although not
playing games. He looked better in every way, and the incision w-as quite healed,
showing however a little keloid change. The right lobe of the liver w’as not palpable.

Section of Surgery

but the left was easily felt slightly below its normal level. A radiograph of the
abdomen (without oxygen injection) showed what appeared to be a diminution in size
of the liver shadow on the right side. Dr. Crawford of the Pathological Department
examined the fteces and urine, and reported as follows: Urine: Specific gravity
1027 ; reaction, acid ; albumin, nil; bile, nil; diastase, 20 units; urea, 3 per cent. ;
deposit, a few crystals of calcium oxalate. Fteces : Bulky brown stool; reaction,
alkaline—urobilin content, normal; microscopic examination shows a few soap crystals,
but otherwise nothing abnormal. Thus the examination did not suggest any
interference with the hepatic function.

FlO. 2.—The microscopic appearances at the junction of the tumour with the normal

liver substance.

The patient was seen again in January, 1923, one year and ten months after the
operation. He was in excellent health, working regularly in an office, and without
complaint of any kind whatever. He has developed very much since the operation
and is heavier (7 st. 12 lb.) and more healthy in appearance than ever before (see fig. 3).
Dr. George Clark of the Physiological Department of the University of Durham
College of Medicine kindly investigated the hepatic function, making detailed analyses
of the urine and fieces on two separate occasions, and the result of the analyses
indicates that the liver is functioning normally.

The patient’s father refused to allow a sample of blood to be taken for estimation
of the blood-urea.

48 Grey Turner: Adenoma removed from the Liver

Results of Analyses of Urine and Fasces twenty-two months after

Hepatectomy.

(a) Urine Analyses .

(1) Twenty-four hours* sample :

Urea (in terms of nitrogen)

Ammonia (in terms of nitrogen) ...

Amino acids (in terms of nitrogen)

(2) After dinner sample :

Urea (in terms of nitrogen)

Ammonia (in terms of nitrogen) ...

Amino acids (in terms of nitrogen)

(3) Further sample obtained a fortnight later :

Urea (in terms of nitrogen)

Ammonia (in terms of nitrogen) ...

Amino acids (in terms of nitrogen)

( b ) Fat Analyses of Fsec

(1) Total fat per 100 grm. dried faeces

(2) Further sample obtained a fortnight later, and i

meal of a known quantity of fatty food.

No increase of fat in the fieces.

The “ lievulose ” test ( Lancet , 1921, ii, p. 1360) is only indicated where there are wide¬
spread or acute degenerative changes, and was not employed.

At this stage, I will briefly refer to the only other case in which I have
had occasion to resect any considerable portion of the liver:—

The patient (Keg. No. 4835) was a woman, aged 33, who was admitted to the
hospital in October, 1911. For twelve months, she had complained of pain in the left
side of the upper abdomen, followed by the development of a “ lump.** The pain
came on in attacks, often just after food, and she stated that the lump got larger
during a seizure. She had never vomited. The patient did her usual household
duties until six weeks before admission.

On admission she was found to be a thin, anaemic looking woman, the mother of
five healthy children, but had thrice miscarried. In the right hypochondrium there
was a large pear-shaped swelling extending downwards from the costal margin
towards the umbilicus and movable from side to side. It therefore resembled a distended
gall-bladder, and that was the diagnosis provisionally made. At the operation it
proved to be a localized growth springing from the left lobe of the liver. It was
suspiciously like a malignant tumour, and as there were no other deposits and no
signs of a mother growth, it was looked upon as a primary carcinoma of the liver.
After careful examination, it was decided that it ought to be removed, and this
operation was carried out. The notes state that 44 the liver was clamped, divided and
sutured with catgut. There was a little oozing, for which a gauze strand was left in
situ and was removed four days later.” I much regret that the record is not more
explicit and that I have no clearer recollection of the exact techique employed, but
fortunately, I do vividly remember that the large tumour was removed and the gap in
the liver repaired without much difficulty and that the patient made a smooth and
satisfactory recovery, leaving the hospital three weeks after operation.

The mass was the size of a closed fist and weighed oz. (fig. 4). Its surface
was nodular, puckered and inflamed, and there were some tags of adhesions
about it. The cut surface showed an appearance at once suggestive of gumma.
The centre was caseating, but the periphery was of solid pearl-coloured nature. A
lymphatic gland from the small omentum presented the same appearance. Microscopic
examination confirmed the gummatous nature of the mass. While in hospital a
Wassermann test was done, but with a negative result. The patient had a course of
antispecific treatment after leaving the hospital, but salvarsan was not employed.
Since the operation she has had two normal children and one miscarriage, and
is now, eleven years later, in good health.

0*775 grm. per cent.
0 048 „

0*017 „

0*949 „

0*076 „

0042 „

1*072 „

0*074 „

0*0077 „

7 es .

after a

32*4

Section of Surgery

Cases in which removal of a considerable portion of the liver may be
looked upon as a legitimate surgical enterprise are few indeed. Up to the end
of 1922 I had performed 14,923 operations. Of these 4,935 have been
abdominal, with about 550 on the liver and its excretory apparatus, and the

Fig. 3.—Photograph of the patient one year and ten months after the operation.
It shows the sear of the incision employed and incidentally the good condition of the
boy.

instances of resection of the liver which I have quoted are the only cases in
which I have felt it justifiable to attempt this operation. Yet, during the
whole of my surgical career I have been alive to the possibilities of partial
hcpatectomy, for my interest in the subject was first aroused nearly twenty-

50 Grey Turner : Adenoma removed from the Liver

five years ago. At that time I assisted the late Dr. George Halliburton Hume,
one of the surgeons to the Newcastle Infirmary, at an operation for the removal
of a cancerous mass secondary to malignant disease of the stomach.

The patient was a woman, aged 48, on whom Dr. Hume had performed pylorectomy
for cancer in June, 1897. She made a good recovery and remained well for eighteen
months when she noticed a lump in the epigastric region. This development was
followed by complaint of pain in the left side, worse after food, and accompanied by
nausea but no vomiting. The lump gradually increased, and when she finally
summoned up courage to return to the hospital in December, 1899, it was the size of a
tangerine orange. It lay midway between the ensiform process and the umbilicus in the
central line. There was no evidence of distant dissemination and no signs of dilatation
of the stomach. On exploration, the mass was found to be a malignant growth in the
margin of the liver just to the left of the gall bladder. There were several omental
adhesions, but after their separation the parts could be fully explored, and as there
was no evidence of any other growths either in the liver or stomach it was decided to

Fig. 4.—Portion of gummatous liver weighing 84 oz. excised from the second case
described in the text. The cut surface is shown on the right.

remove the recurrence. This was done by withdrawing the affected portion of liver
from the abdomen, transfixing its base with a couple of knitting needles, and
surrounding the pedicle thus formed with an elastic ligature. The portion of liver
bearing the growth was then cut away, and the stump treated extraperitoneally. The
patient made a good immediate recovery, and was able to leave the hospital about
eight weeks after the operation. Six months later she appeared in good health, but
was losing weight, and as far as I can recollect, she died within twelve months from the
operation with local recurrence and evidence of secondary deposits in the liver.

I have now and again removed a portion of the edge of the liver during the
performance of partial gastrectomy or cholecystectomy, and have come to look
upon this as a procedure which can be carried out with impunity.

My experience of this limited type of excision began with the first gastrectomy
that I ever performed in the case of a patient, J. H., aged 87 (Keg. No. 1062). The
growth, a pyloric one, was adherent to the liver edge, but this was clearly a direct
extension, and there was no evidence of dissemination. The liver was clamped well

■Section of Surgery

beyond the affected portion, and the latter was cut away, the gastrectomy being
completed by the method then known as Billroth No. 11. The clamp was removed
from the liver on the third day. To my great disappointment, the patient died eight
days later from a duodenal leak, but examination showed that the liver incision was
healing satisfactorily and had in no way contributed to the unfortunate result. That
case greatly encouraged me for it showed how direct invasion as opposed to dissem¬
ination need not prove a bar to successful operations for cancer of the viscera.

Though the indications for resection of any part of the liver are undoubtedly
few, the surgeon may be called upon to perform it in the course of some
operation in which interference of this kind has not been contemplated, and
therefore we should be prepared with a suitable technique which may be used
when the occasion does arise.

In spite of the fact that the opportunities are few, the total number of
operations recorded is comparatively large, probably because almost every
instance has been published. The operation has been carried out for a whole
variety of conditions. Many surgeons hold that it should be part of the routine
operation for malignant disease of the gall-bladder, and they recommend that a
wedge-shaped portion of the liver should be excised whenever the removal of
such a gall-bladder is undertaken. Others limit the interference with the liver
to those cases in which there is evidence of a direct extension to that organ.
My experience has taught me that when malignant disease of the gall-bladder
can be recognized by the naked eye, no operative interference—whatever the
type—can be expected to lead to permanent cure, and that the operation of
excision is only a palliative measure. Under these circumstances I should not
consider it justifiable to incur any great additional risk in dealing with it.

Direct extension of malignant disease from the stomach or colon may
render removal of a portion of the liver necessary, and I think this will become
one of the most frequent indications, especially as it usually only involves the
removal of a slice or wedge from the edge of the organ. In cases of this kind,
such an extension to the liver need not in itself be a bar to successful operation,
but of course it would be useless to carry out this portion of the operation if
the extension of the growth in other directions rendered its removal unprofitable.

The operation has been extolled, by some writers, for hydatid disease, but I
am satisfied that this is never an absolute indication and that it should only be
carried out when the conditions are such that the resection of a tongue-shaped
portion of liver bearing the hydatid (or it may be a simple cyst, as in Sir John
Bland-Sutton’s case) is simpler and safer than the other available methods of
dealing with such cysts.

Tumours of uncertain nature have often led to this operation being carried
out, and that was so in my own cases. Many of these have turned out to be
angiomata and some have been solid adenomata, and both of these may, in my
opinion, be legitimately dealt with in this way, provided the local conditions
will admit of a clean excision without approaching too near the hilus.

In other cases, tumours regarded as localized primary malignant disease, or
as localized secondary masses, the primary growth having been dealt with, have
also furnished examples of the cases in which the operation has been success¬
fully carried out; and I should look upon these conditions as perfectly justifiable
indications, considering the doubt that most often exists with regard to the
naked-eye diagnosis, and the very hopeless outlook when nothing can be done.

Several times granulomata, and especially gummata, have been removed
from the liver, always under the impression that the surgeon was dealing with
malignant disease. Of course, this is an error which is less likely to occur at

52 Grey Turner: Adenoma removed from the Liver

the present time, and I have learnt that gummata, even when localized,
may usually be distinguished by the naked eye. They are usually smaller
than malignant nodules. Their surface is rounded and not umbilicated,
and there is much more perihepatitis than is the case with new growths.
If real doubt exists, I should* not hesitate to remove a portion for section,
and either perform a secondary operation or carry out the operation
of excision there and then on the evidence furnished by a frozen section, pro¬
vided that some pathologist, in whose opinion I had confidence, would take the
responsibility of giving a definite opinion. I must say that in practice it usually
means that when there is doubt, it is better to wait until paraffin sections can
be made and examined.

Riedel’s lobe has been excised. This is undoubtedly sometimes a tempta¬
tion, because the pedicle which connects the latter with the liver is often thin
and very easily dealt with. However, I question very much if the mere
presence of the lobe is ever the cause of symptoms, and the surgeon should
carry out a most careful investigation before deciding that the lobe can of
itself have caused the symptoms and therefore be justifiably removed. Of
course, there may be some cases in which the persistent dragging of such a
lobe, or its mere presence, has become an obsession to the patient, but usually
I believe there is some other explanation of any discomfort, mental or
otherwise, from which they may suffer.

Finally, the subject is intimately associated with the question of injuries
of the liver for the treatment of lacerations of the organ, and the removal of
some portion which has been nearly separated by the traumatism presents
many of the same technical difficulties.

The great problem in dealing with resection of the liver has always been
the control of haemorrhage, not only at the time of the operation, but per¬
manently. Let us review briefly the methods which have so far been
employed.

Formerly, it was a question of whether or not the tumour was sufficiently
pedunculated to allow of its being brought outside the abdomen and the pedicle
treated extraperitoneally. This method is now seldom, if ever, employed, but
it should be borne in mind, for it can be carried out with success if necessary.
The indications for its use may be some well pedunculated tumour with a very
vascular pedicle such as is found in some of the angiomata; or else the inexperi¬
ence of the operator. In actual practice, the tumour is brought outside the
abdomen and the pedicle is transfixed by two stout needles. Wyeth’s pins or
thick knitting needles will serve the purpose. An elastic ligature (such as a
piece of fine rubber drainage tube) is then wound tightly round the pedicle on
the proximal side of the needles and the remainder of the parietal incision is
closed. The needles lie on the abdominal wall, pads of gauze intervening.
As a last step the tumour may be cut away, or this may be deferred for
48 hours until the pedicle has become adherent to the abdominal wall. In
either case the knife or cautery is employed, and the stump is dressed anti-
septically. In about a fortnight the pedicle will have become firmly adherent
and the process of its isolation will be well advanced so that the needles can
safely be removed, but it is usually many weeks before the stump heals over.

But the ideal plan is to carry out the resection and to repair the wound in
the liver by immediate suture with closure of the abdominal wall. For this
type of operation to be carried out, means must be provided both for the
temporary and permanent arrest of haemorrhage. So far as the temporary
a rrest is concerned, the methods available are ;

Section of Surgery

(1) That originated by Hogarth Pringle of Glasgow, in which the blood¬
vessels entering the liver are either caught and held, or are temporarily clamped.
This is carried out by the fingers or by a special clamp (Baron's) compressing
the structures in the free edge of the lesser omentum. This plan has many
possible advantages, and has perhaps not received the consideration it deserves.

(2) The second plan is again the manual control of the tissue to be divided,
an assistant taking a firm grasp of the organ on either side of the proposed
incision. The liver is very plastic and can endure quite firm pressure without
harm, provided that it is applied slowly and steadily. This method is efficient,
but it is irksome, and the hands of the assistant are very often in the way.
Except, therefore under special circumstances, it is not a method which can be
universally relied upon.

(3) Clamps may be used, and are often effective because of the plasticity
of the liver substance, but they undoubtedly crush the tissue severely and are
not suitable for holding the thicker portions of the organ. There need be no
hesitation in using them for grasping the tissue which is to be removed, but for
use on the proximal side there are many disadvantages, except in those cases
where the liver tissue is thinned out to an unusual degree. In some of the
cases of pedunculated tumour, they have been used with great success.

(4) A tourniquet may be applied in certain circumstances, and with a
proper introducer, an elastic ligature can be passed right through the
substance of the liver and tied in such a way as to control the blood supply
to a particular area, but this method rather interferes with the subsequent
suture and permanent arrest of haemorrhage.

(5) Sometimes the thermocautery has been used to actually make the
incision and at the same time staunch the bleeding, and this is a method
which has proved satisfactory in the hands of Keen, of Philadelphia, who
removed the greater part of the left lobe by this method, 20 to 30 minutes being
required to cut away the mass. I would certainly adopt this plan, probably in
association with other methods, when the line of section has to be made in close
proximity to a malignant growth.

The next question is the permanent arrest of haemorrhage and the closure
or other treatment of the liver wound. For the permanent arrest of
haemorrhage, the branches of the hepatic artery may be caught and tied. The
big venous channels may similarly be surrounded by a purse-string of catgut,
which must be tightened slowly and carefully, as it may easily cut through the
friable liver substance and fail in its purpose. For the rest, the mere apposi¬
tion of the surfaces will usually be enough to stay any further haemorrhage.

The great difficulty about the suture of the liver is the friability of its
substance and the readiness with which sutures cut out or cut through its
substance. It is only the tough capsule which ever enables the sutures to hold.
For this reason various devices have been introduced. Special needles are
recommended. Those introduced by Kousnetzoff are blunt, and are flattened
from side to side so as to cut the liver substance as little as possible.
Payer has used magnesium plates in imitation of the old button
stitch. Various complicated methods of chain suture have also been devised
and extensively used in experimental work on animals. For these sutures
various substances have been employed—silk, catgut, kangaroo tendon, strips
of fascia and ribbons of gauze.

In my view, we should have at our command some method of liver suture
which is simple, and which does not require any special instruments or suture
material. Invariably, special apparatus which is only very seldom required is

54 Grey Turner: Adenoma removed from the Liver

mislaid or is out of order when wanted. I would, therefore, especially direct
your attention to the method of liver suture which I employ, and which has
the advantage of fulfilling the indications of both the temporary and permanent
arrest of haemorrhage, while greatly facilitating the application of sutures. It
was suggested to me by a paper published in the Annals of Surgery for
November, 1907, by Van Buren Knott, and entitled “ A New Liver Suture.”
The plan, as described by Knott, consisted in passing a stout catgut suture
parallel to the line of the proposed incision, which served to give a hold to the
sutures of apposition which are passed and tied over this buried strand. The
passage of this suture requires a special needle, and as originally described, it
did not provide a means af arresting haemorrhage until the sutures of apposition
were tied (fig. 5). I have modified the method as shown in the diagram, and
in the specimens which I have brought with me. Instead of burying a single
strand longitudinally, I pass a series of loops of catgut into the liver substance
parallel to the proposed incision. For this purpose I use an ordinary large size

Fig. 5.—Illustrating the method of liver suture employed. A couple of hepatic veins
are shown surrounded by purse-string sutures of catgut.

(Reproduced by kind permission of Messrs. Cassells.)

half circle round needle with a circular eye threaded with No. 3 chromic cat¬
gut. Each loop is tied as passed, and serves to arrest the haemorrhage in the
area of liver in its grasp. Some vessels will escape, but they may be caught
separately and tied or surrounded with a purse-string of finer catgut. The
sutures used for the apposition of the liver are then passed over the longitudinal
loops which serve to prevent them cutting out, and provide quite a sufficient
support for the apposition of the cut surfaces, even when the latter are a little
reluctant to lie together. The exact apposition of the edges can be secured
by a few additional interrupted sutures passed here and there as required.

This method answered most admirably for dealing with the large tumour
which I have brought before your notice this evening, and I can recommend it
with confidence. The method is much easier in its application than to
describe, but I trust that the drawings and specimens will make it
intelligible.

Section of Surgery

In dealing with an actual case where hepatectomy is necessary the
various steps required are as follows : (1) Adequate exposure; (2) exploration
and decision; (3) temporary control of haemorrhage; (4) the actual excision
of the involved area; (5) permanent arrest of haemorrhage and repair of the
liver wound; (6) toilet of the peritoneum and closure of the abdominal
wound.

The parietal incision to be employed will depend upon the situation of the
tumour and the build of the patient. The exposure must be sufficient, and for
most cases, some type of vertical incision will be best, but the surgeon must
never hesitate to make a cross cut if additional room is required. If the tumour
is far back on the right lobe, then a long oblique incision 1 in. below the
costal margin will be the best to employ. It may be possible to obtain
much help in exposure from the use of the reverse Trendelenburg posture, the
elevation of the lumbar region and the division of the triangular ligament.
Gauze packed over the dome of the liver as described by Masson may also
be an aid.

As soon as the abdomen is opened, the condition must be carefully ex¬
plored in order to determine the feasibility of its removal. For this purpose,
adherent omentum may have to be separated or adhesions to the parietes and
the other viscera divided. This may be done without hesitation, for some
of the most favourable cases are associated with such adhesions, and their
separation may bring an apparently hopeless looking condition within the
range of safe surgical enterprise. The greatest advance in abdominal
surgery to which I have been witness is this preliminary examination of
pathological conditions under the guidance of the eye, and the more thorough
mobilization, by separation of adhesions and unimportant peritoneal folds,
avascular ligaments, &c.

If there is any question of malignancy, a careful search must be made on
the one hand for a primary focus, and on the other for further deposits in the
liver. In illustration of the latter there are the not uncommon cases of
malignant disease of the gall-bladder with direct extension to the liver, which
could easily be removed by a moderate wedge-shaped excision, but in which a
secondary deposit present on the dome of the liver renders excision valueless.
It is most important to determine the relation of the tumour and the incisions
that will be necessary for its removal to the hilum, as this part of the liver
must not be encroached upon. The gall-bladder and cystic duct can of course
be removed if necessary.

Whenever possible the part to be excised should take the form of a V,
but to avoid going too near the hilum it may be necessary to leave the
point of the latter rounded or rectangular. When the part removed is
not too large, the gap can be brought together and sutured, but if this is
not possible, the apex may be dealt with in this way and the remainder left
gaping.

Every effort should be made to stay oozing. A good deal of the oozing may
be due to venous engorgement, and will stop when the liver is allowed to fall
back into position. In spite of great care it may be necessary to leave in a
gauze pack, and in order to exert pressure on the bleeding area, one or two
sutures may be passed through the liver on either side, so that the
edges of the gap may be drawn together over the gauze. It will not often be
possible to remove the gauze with safety sooner than ten or twelve days after
operation. In all cases, drainage should be provided lest there be bile
leakage.

Wright: Primary Carcinoma of the Liver

In dealing with angiomas, great care must be taken to cut wide of the
actual tumour, and to avoid puncture of the latter, as most serious haemorrhage
may result.

In conclusion, I suggest:—

(1) That the method I have described is suitable for dealing with every
kind of wound necessary for resection of portions of the liver.

(2) That small resections of the liver edge can be safely dealt with by
cutting into its substance obliquely so that the edges of the wound fall together
like the flaps of an amputation, and can be then readily sutured by any
simple method.

(3) That when the section of the liver must be made in close proximity to
a malignant growth the actual division of the liver should be made with the
cautery.

(4) That the method of extraperitoneal resection after transfixion of the
pedicle and elastic ligature may occasionally be peculiarly applicable and need
not be despised.

(5) That the after-history of the cases presented shows that a considerable
portion of the liver tissue may be removed without interfering with the
subsequent health of the patient.

Primary Carcinoma of the Liver excised by Operation.

By Garnett Wright, F.R.C.S. (Manchester).

The occasions on which any one surgeon can meet with liver tumours
which are operable must of necessity be limited, and this is especially so in
the case of malignant neoplasms. It is, therefore, useful to pool our
experiences of such cases, and this is my object in reporting the following
case:—

The patient was a man, aged 60, whom I saw for Dr. Marsh, of Macclesfield, on
June 21, 1920. His illness dated back for some six weeks; during that time he had
suffered from griping pains in the upper abdomen, shooting through to the back and
to the right shoulder. During this period a lump had formed which had increased in
size. There was nothing further of note in the clinical history, except that for some
months he had had increasing constipation and occasional passage of bright red blood,
which he attributed to piles. He had passed no mucus and had had no diarrhoea. He
also had some nocturnal frequency of micturition.

On examination he was found to be in fairly good general health. In the abdomen
there was a large oval mass on the right side of the umbilicus reaching to the costal
margin. It was not fluctuant and moved freely with respiration. It was dull all over
on percussion and the dullness was continuous with the liver dullness. The mass
could not be pushed back into the loin. I thought I had probably to deal with a much
enlarged and adherent gall-bladder.

Operation was performed on July 8, 1920. The abdomen was opened through the
right upper rectus muscle, when the mass was seen to consist of a large spherical
tumour in the right lobe of the liver. It was not pedunculated but was deeply
embedded in the liver substance and was about the size of a Jaffa orange. The gall¬
bladder was lying stretched over the left margin of the growth and there w'as a small
secondary nodule in the liver substance, about the size of a pea, lying near the sharp
margin of the liver close to the cleft for the falciform ligament. No further growths
could be found in the liver, and as no primary tumour could be discovered anywhere in
the abdomen, I decided that I had to deal with a primary carcinoma of the liver, and
that I would attempt to excise it. I first divided the cystic duct, as the gall-

Section of Surgery

bladder was so closely applied to the tumour that it was necessary to remove it.
At this stage I noted that the hepatic artery was much enlarged and tortuous.
I began by attempting to prevent haemorrhage by mass ligatures through the
liver tissue, but I soon abandoned this and cut through the liver tissue. In
the deeper parts the tumour began to shell out, so that I completed the separation
by shelling out the tumour from the liver. My assistant controlled the bleeding by
pressure of hot swabs, and when the growth had been removed all large veins and
spurting arteries were caught with forceps and ligatured. An attempt was made to
close the gap in the liver by means of mass sutures but too much had been removed
to allow of complete closure. The wound in the liver was therefore packed with
gauze and the abdominal wall was closed. The gauze pack was removed at the end
of three days and the patient made a good recovery except for an attack of double
glaucoma for which Dr. McNabb did a double iridectomy. He is still alive and in
good health at the present time.

The specimen removed was hardened and then cut across and it shows
a well encapsuled tumour with a very varied appearance, being bile-stained in
some places and showing haemorrhages and degenerations in others. The
small secondary nodule can be seen quite separate from the main growth.

The tumour was examined microscopically at the time by Professor H. R.
Dean and recently by Dr. Eyrie and Professor Shaw Dunn, and they all
three came to the same conclusion that it was a primary carcinoma of liver
cells. Dr. Ryrie has kindly given me a detailed pathological report as
follows:—

“ The tissue submitted for examination consists almost entirely of new growth,
pale in colour and often slightly bile-stained, with occasional areas of haemorrhage.
It is well defined from the small margin of liver tissue remaining, but in this liver
tissue are several small pale, spherical nodules apparently quite separate from the
primary mass.

“ Microscopic Examination .—The structure varies considerably in different parts.
Most sections show a solid mass of closely packed tumour cells devoid of any definite
histological arrangement. Blood-vessels are scanty, but there are large sinus-like
blood spaces, with only an imperfect endothelial lining separating the tumour cells
from the blood stream. In these spaces tumour cells can sometimes be seen among
the blood corpuscles. Elsewhere the tumour cells are arranged in thick trabeculae
separated by fine strands of connective tissue and small blood-vessels, and frequently
the cells are arranged in tube-like structures in the lumina of which a brownish
stained material occurs, apparently a product at least related to bile—mingled with
products of cell degeneration.

“ There are areas of haemorrhage. In some areas the tumour cells appear to have
undergone atrophy, leaving a vascular cellular stroma where connective tissue cells are
proliferating. Areas of necrosis also occur distal to the vessels, so that in these areas
the tumour has a definite perithelial arrangement.

“ In the sections the main tumour mass appears encapsuled. Encapsulation of the
secondary nodules is less perfect, so that the tumour cells are sometimes in close
opposition to liver cells along an irregular frontier. Tuntour cells are seen in vessels
distal to those secondary tumours. The liver immediately around the tumour is
cirrhotic, secondary to the tumour process, but away from the tumour the liver tissue
is not cirrhotic.

u There is extraordinary variety in the size and shape of the cells of the tumour
and many show degenerative changes, vacuolation, and coarse granularity. Nuclear
variations are many. Nuclei of great size and very irregular shape are common, and
binucleated and multinucleated cell masses are frequently seen. Great increase in
size and number of nucleoli constitutes a prominent feature. Mitotic figures are
present, but not numerous.

“ The very atypical structure of the tissue, the aberrant types of cell, nuclei and
nucleoli, the presence of secondary growth in the liver, the imperfect capsulation of

58 Wright: Primary Carcinoma of the Liver

these growths, the presence of tumour cells in the vessels, and the areas of necrosis,
are findings suggestive of a malignant growth. Nevertheless, clinical malignancy in
the sense of capacity to cause generalized metastases is not a necessary corollary of
even extreme anaplasia in these tumours, and it is doubtful whether the cells seen in
the vessels are viable outside the liver. The non-committal term 4 hepatoma * lias
on these grounds tended to replace the term 4 liver cell carcinoma.’ ”

The epithelial elements in the liver from which a primary carcinoma may
arise are : (1) the epithelium of the bile-ducts, and (2) the liver cells.

These tumours have been classified into three varieties: (1) the large
solitary carcinoma ; (2) the nodular variety, and (3) multiple carcinoma.
The last named variety is the kind found complicating cirrhosis of the liver.
The nodular variety consists of a collection of malignant nodules, one of
which has probably been the primary growth, the others being metastatic.
The tumour for which Keen excised the left lobe of the liver was of this
nature.

The large solitary growths, of which my case is an example, are inte¬
resting because they do not seem to be so malignant as the other varieties,
and are said not to produce metastases outside the liver. Some indeed deny
that they are malignant and the name hepatoma has been given them.
Microscopically the evidence of malignancy is quite definite. The irregular
character of the cells, and their nuclei; the occurrence of binucleated cells
and the presence of mitotic figures in the nuclei all point in that direction.
In addition, one section I show you demonstrates the presence of tumour cells
in a vessel beyond the periphery of the tumour, and although the tumour is
for the most part well encapsuled, in some places the tumour cells are in
close contact with the liver cells. Finally there is the presence of a secondary
nodule quite separate from the primary tumour which can be seen in my
specimen.

From the clinical side, however, there seems to be no doubt that the
malignancy, if any, is of a low grade. In my case operation two and a half
years ago, of a somewhat incomplete nature, has not been followed by recur¬
rence. This is in sharp contrast to the results obtained in carcinoma of the
nodular variety, where recurrence has been the rule.

The technique of partial resection of the liver has been chiefly concerned
with the control of haemorrhage, and various methods have been adopted to
isolate the operation area, such as interlocking ligatures, or elastic tourniquets
round the base of the tumour, kept in position by knitting needles passed
through the substance of the liver. The drawback to all these methods is
that while they are easy to apply to small and pedunculated tumours they are
very difficult to use in the case of larger tumours which are deeply embedded
in the substance of the liver. From my experience in this case, and in some
cases of excision of the gall-bladder with a wedge of liver tissue, I think the
simple method of cutting boldly through the liver tissue is quite safe. It is
easy for an assistant to control the haemorrhage from the cut surfaces by
pressure with a hot swab. When the excision is complete the swab is
removed gradually, the vessels being picked up with forceps and ligatured
in the usual way, or by under-running them. The cut surfaces of the liver
should then be drawn together by deep sutures if possible. If not, then packing
should be resorted to.

In any future case I would certainly excise more boldly and widely than
I did in this instance.

Section of Surgery

A Case of Resection of the Liver for Malignant Disease
spreading from the Gall-bladder.

By Claude Frankau, C.B.E., D.S.O., F.R.C.S.

A WOMAN, aged 40, came under my care in April, 1913, for recurring
attacks of gall-stone colic. The history and signs were typical and there was
no reason to suspect any complication, but at the operation it was found that
in addition to stones there was malignant disease of the gall-bladder with
evidence of infiltration of the liver and at one point a definite secondary nodule
on the convex surface of the liver. I decided to attempt to eradicate the
disease by resection of the affected portion and accordingly with a scalpel
excised the gall-bladder together with a wedge of liver measuring 3 in. wide
at its base, 3£ in. deep, and rather over 2 in. thick at the deepest part of

A, Liver ; B, Interposed omentum ; C, Suture.

the incision. The line of incision was well clear of any visible growth.
Haemorrhage was brisk for the moment but was readily kept in check by
digital compression of the liver on either side of the incision and by a gauze
pressure. I then attemped to suture the cut edges together by means of stout
catgut ligatures on round-bodied needles passed deeply through the liver
substance: this failed as the stitches cut out at once. As I was anxious to
suture the gap rather that trust to gauze plugging I brought up a large fold
of great omentum in a double layer into the liver incision and overlapped both
cut edges with it. The sutures were then passed through omentum and liver
as shown in the diagram (see figure): they held firmly and good coaptation of
the cut surfaces with complete haemostasis was readily obtained. The portion
of omentum interposed was then detached from the main omental sheet by
ligaturing it off: and the abdomen was closed, a tube drain being left in leading
down to the ligatured cystic duct. #

Recovery was uneventful and the patient was alive in August, 1914, and
apparently well; unfortunately she could not be traced after that date, but as
she had survived for fifteen months the result justified the risk taken at operation.
The diagnosis of carcinoma was confirmed by microscopical examination.

60 Philip Turner: Excision of Adenoma of the Liver

I have used the method of interposing omentum between cut or torn
surfaces of liver in a number of cases since and have found it satisfactory.

Case of Excision of an Adenoma of the Liver, which had
ruptured spontaneously, causing Internal Haemorrhage.

By Philip Turner, M.S., F.RC.S.

I have only once removed a primary growth of the liver but that was in
the most remarkable abdominal emergency with which I have ever had to deal.
The patient, a married woman, F. C., aged 29, was admitted to Guy’s Hospital
on November 16, 1913, for abdominal pain and vomiting. The pain, which
was very severe, had come on suddenly about ten hours before admission and
the vomiting had been frequent. There was no history of injury; she had
never before had any severe attack of abdominal pain, and there was no history
of any digestive troubles.

On admission the abdomen was moderately distended and there was general
pain, rigidity and tenderness : signs of free fluid were found. There was a
marked degree of collapse ; the pulse was very weak and rapid, the skin cold,
and the patient was very pale. Menstruation was regular and normal.

No definite diagnosis was made before operation, but the pallor, condition
of the pulse, and the presence of free fluid, suggested an internal haemorrhage,
most probably the result of a ruptured ectopic gestation.

When the abdomen was opened the peritoneal cavity was found to be full
of blood, but both the tubes and the ovaries were normal. On the abdominal
cavity being searched for the source of the haemorrhage a large dome-shaped
tumour was felt projecting from the inferior surface of the right lobe of the liver.
The incision was prolonged in an upward direction to bring this into view, and a
rent, about 3 in. in length, from which blood was freely escaping, was found in the
most prominent part of this tumour. Attempts to close the rent and check
the bleeding by sutures were not successful, as the stitches, owing to the friable
character of the surrounding tissue, which had the consistency of placenta, at
once cut through. For the same reason an attempt to plug the rent with
gauze led to further laceration and increased the haemorrhage. Removal of the
tumour appeared to offer the only prospect of stopping the bleeding and this
was done by Pacquelin’s cautery. The tumour did not extend deeply into
the liver substance: there was no pedicle, though the base was slightly
constricted, and the charred area of the liver left after removal of the tumour was
about the size of the palm of the hand. There was no bleeding from this surface.

The condition of the patient was very grave: She was infused but died
about an hour after the completion of the operation. At the post-mortem
examination the stomach and intestines were normal: the stomach was full of
bile-stained fluid. On the under surface of the right lobe of the liver there
was irregular bruising and superficial laceration over an area the size of the
palm of one’s hand, corresponding with the site from which the tumour had
been removed. There was nothing found in the post-mortem room to indicate
the nature of the tumour. It appeared to have been attached to the liver
rather than to have arisen in its substance and there were not any metastases
to indicate that it was malignant. Macroscopically one would have judged
that the whole tumour had been removed. Histological examination of
portions of the liver which had been in contact with the growth showed
normal hepatic tissue. The other viscera were normal.

Section of Surgery

Owing to its friable nature the tumour did not make a satisfactory museum
specimen and it has not been preserved, but a coloured drawing made to scale
at the time gives a good idea of its appearance. Its length and greatest
diameter were both about four and a half inches.

The tumour was examined histologically by Dr. G. W. Nicholson, who
reported as follows :—

“The sections represent part of a large adenoma of the liver. It consists of
irregular trabecula of somewhat small hepatic cells and contains no ducts or portal
systems. It is entirely without a capsule. Parts of it have undergone haemorrhagic
necrosis. Others show the result of old hamorrhages in the shape of a fibrinous deposit
between the remains of the epithelial cells. 1 ’

At the operation the growth was thought to be either a sarcoma or possibly
an angeioma. No history of injury could be obtained from the patient and
careful inquiry of her relatives failed to produce any account of an accident.
Presumably, however, some slight injury, possibly even muscular action, must
have caused the haemorrhage. Doubtless the tumour was much smaller before
the haemorrhage occurred and its friable character was due to its being
infiltrated with blood-clot. Removal by the cautery was rapidly carried out
and there was no haemorrhage from the cut surface. Death was due to the
haemorrhage rather than to shock from the operation.

Case of Primary Tumour of the Liver removed by Operation.
By Frank Kidd, M.Ch.Cantab., F.K.C.S.Eng.

CASE history: Female, aged 57, admitted to the London Hospital on
July 5, 1911. Sudden onset twelve days ago, aching pain in right iliac fossa,
burning pain, accompanied by diarrhoea, no vomiting. During the last few
days has been passing urine more frequently, has had to get up five or six
times at night and then passes only a little at a time. She had a similar
attack of pain two months ago, but at that time there was no trouble with the
urine.

Examination : Temperature 99’5 U F., pulse-rate 94 to the minute.
Abdomen moves satisfactorily; no rigidity; tenderness all over the right flank.
A large smooth rounded swelling can be felt in right flank.

Operation: This patient was admitted during the evening. I thought she
was a case of subacute appendicitis with abscess formation, as I had to operate
on her in the middle of the night, having already done a number of acute
appendicitis cases consecutively. I turned the right rectus inwards and on
opening the peritoneum found that the swelling was not an abscess of the
appendix, but a tumour the size of a cricket ball growing in the substance of
the right lobe of the liver towards its anterior margin. A rapid exploration of
the abdomen revealed no other lesion, and particularly nothing in the nature
of a primary growth to which the tumour could be secondary. I came to the
conclusion that I was dealing with a primary tumour of the liver and decided
to remove it. I was accustomed to use Cullen’s blunted needles for stitching
•the kidney substance and always had some at hand. I therefore passed
splinting sutures of stout catgut some 2 in. away from the growth through the
liver substance with Cullen’s blunted needles, each suture taking a bite of
about 2 in. and overlapping its fellow. Having inserted these sutures and tied

62 Kidd : Primary Tumour of the Liver ; Walton: Hepatectomy

them I cut out the tumour enclosed in a wedge-shaped area of liver substance.
I picked up one or two large arteries that were spurting, with artery forceps,
and tied them off. I then placed catgut sutures threaded on the Cullen’s
needle outside the splinting sutures on each side and drew the sides of the
wedge together. The cut in the liver came together very neatly and the
splinting sutures stopped all the venous haemorrhage. I was surprised to find
how little difficulty there was in the whole procedure.

Progress: As regards the operation wound the patient did well, but there
was an extraordinary heat wave that week, the temperature rising each day to
105° F. in the shade. She died from heat stroke on July 10, 1911, in company
with many other victims of the heat lying in the wards of the hospital.

Necropsy, July 11, 1911: There was a little blood in the peritoneal cavity.
The wound in the liver was healing satisfactorily. There was a little
fibrinous peritonitis in the region of the wound of the liver. Not a sign of
any neoplasm could be found in any organ of the body, though examination
of the head was not permitted. Nothing was found as a cause of death, the
organs appearing normal.

Dr. Hubert Turnbull at that time reported the tumour to be a Grawitz
tumour. On section it presented to the naked eye many areas of fatty
degeneration and looked exactly like a Grawitz tumour of the kidney. He has
recently made a further investigation and reports that it is an adenoma of the
liver. He states:—

“ The cells are polygonal and are arranged in solid masses, which are separated into
somewhat lobular areas by capillaries and capillary veins. The cells, with few ex*
ceptions, are completely vacuolated. This was probably due to glyconic infiltration, but
unfortunately no sections were prepared to demonstrate fat or glycogen. Largely owing
to this change in the cells the tumour was originally reported to be a Grawitz tumour.
Now, in the first place, the term 4 Grawitz tumour of the liver ’ is absurd, because the
tumours described by Grawitz (Virchow’s Archiv , 1883, xciii, p. 39) were in the kidney.
In the second place, I am now satisfied that it is not a 4 heterotopic, hepatic hyper¬
nephroma’ (Birch-Hirschfeld, 4 Grundriss der allgemeinen Pathologie,’ 1892), but is a
tumour composed of hepatic cells—a rare form of hepatic adenoma.”

Mr. A. J. Walton.

My own experience of hepatectomy is based on three cases. They were all
examples of a spread of carcinoma to the liver from the gall-bladder. In each
case a relatively large portion of the liver was removed, and although at the
time one was struck with the ease and simplicity with which the operation
itself was conducted, and with which the haemorrhage was controlled, I am
very doubtful whether operations of this nature are justifiable, for my three
patients all had recurrence either in the peritoneum or the liver within a few
months, the longest period of apparent freedom being six months. For less
malignant conditions the operation holds, however, a very distinct place, and
may be found useful in one of the following conditions :—

Adenomata .—These tumours, although extremely rare, form localized and
sharply-defined tumour masses, generally in the right lobe, and will cause
symptoms only from their size and local pressure, so that if removed completely
they will probably not be followed by any recurrence.

Primary Carcinomata .—In certain cases carcinomata of the liver, as inf
some of those shown to-night, will form a localized tumour mass which is
capable of removal. The prognosis, however, is much less likely to be
satisfactory, for it is almost impossible to determine whether or no there are
small outlying nodules in the rest of the substance of the liver.

Section of Surgery

Carcinoma Secondary to the Gall-bladder ,—Many of these cases appear to
be quite localized and capable of removal, but, as my own cases have shown,
it is probable that when once the growth has extended into the liver substance
there has been a microscopic spread either into the lymphatics in the gastro-
hepatic omentum or round the head of the pancreas, or that there are other
minute secondary growths in the rest of the liver and the peritoneum. Even if
it be considered justifiable to remove such a growth, it is well to point out that
care must be taken to avoid two errors. In the first place, chronic cholecystitis
may closely resemble a carcinoma, and a large wedge of the liver may be taken

Fig. 1.

Fig. 2.

away in order to remove an inflammatory change which certainly would have
cleared up after a simple cholecystectomy. The other error is to regard as a
primary carcinoma of the gall-bladder one which is secondary to a relatively
small growth elsewhere, such as in the liver or colon, for now and again large
masses of secondary growth appear to be almost wholly limited to the gall¬
bladder, and thus it is easy to mistake this condition for the primary growth.

Cysts of the Liver .—The ideal treatment for cysts, whether they be hydatid
or retention cysts, is certainly excision, but, owing to the enormous size which
they may sometimes reach, such an operation is rarely feasible. When,

64 Walton: Hepatectomy; Nitch: Carcinoma of Adrenal “ Rest”

however, the mass is situated at the edge of the liver, aud is the only focus, an
operation of this sort is easily performed.

Haemangiomata .—In certain cases a large tumour mass may arise in the
right lobe of the liver, which appears to be quite localized, and to be capable
of excision. It is, however, very doubtful whether a partial hepatectomy will
be successful in such case, for an examination of those cases which have come
to post-mortem show that not infrequently haBmangiomatous masses in the
liver are not only multiple, but may be associated with similar conditions
within the spleen.

As regards the actual technique of the operation, my own experience has
been that it is relatively simple, and that the complicated technique which has
been so often described is rarely necessary. Owing to the wide wedge shape of
the liver, clamps are rarely satisfactory, and it is almost impossible to control
the deeper vessels with their help. It is far better that an assistant should
evert the liver and strongly grasp it on either side of the tumour with his
hands. By this means the haemorrhage is controlled. The tumour can then
be removed, being in part freely excised and in part enucleated. This step is
best carried out with scissors. It is in the method of suture of the resulting
wound that so many different steps have been advocated. Much stress has
been laid on the friability of the liver substance, and a great many devices
have been introduced for the purpose of suturing the rent. The majority of
these are unnecessary. If wide mattress sutures of stout catgut are passed
through either side of the wound they will be found to grip the liver substance
firmly. However, when they are tied, the wound tends to gape on one side.
This is easily overcome by passing further strands of stout catgut under the
loops of the mattress sutures before they are tied (see figs. 1 and 2, p. 63). After
the mattress sutures are tied, these accessory loops are tightened, and will be
found to give perfect apposition of the cut surfaces, and to control all
haemorrhage completely.

Mr. Cyril Nitch.

The specimen I am showing is that of Carcinoma of an Adrenal “ Best ”
in the Liver.

This specimen contains a lowly lobulated mass 2 in. in diameter and
sharply marked off from the hepatic tissues. Microscopically, the growth
presents the appearance of a typical adrenal carcinoma. The patient was a
female, aged 54, who had suffered from attacks of abdominal pain and
vomiting for many years. For three months there had been a dull aching
pain in the right side of the abdomen and progressive loss of weight.

On examination: There was a hard, nodular mass in the upper part of the
right iliac fossa which appeared to be connected with the caecum. The liver
dullness extended to the upper limit of the growth.

Operation, July, 1910: The growth was situated in a lingual lobe of the liver
and looked exactly like a metastatic deposit. Every abdominal organ was
carefully examined (including the kidneys), but no primary growth was
discovered. Partial hepatectomy of a portion of the right lobe of the liver
successfully carried out. Becovery uneventful.

In August, 1911, she was in good health and had gained weight, but she
died in March, 1912, of cachexia with ascites and a large, hard, nodular liver.

Section of SurQen?.

SUB-SECTION OF PROCTOLOGY.

President of Sub-section—Sir Charters Symonds, K.B.E., C.B.,jM.S.

A New Method of treating Ischio-rectal and other Abscesses.
By J. P. Lockhart-Mummery, F.B.C.S.

The treatment of an ordinary subcutaneous abscess does not make much
appeal to the modern surgeon, who generally leaves such cases to his assistant.
The treatment is summed up in a few words : Open the abscess as aseptically
as possible and put a drain into it.

At first sight this treatment does not seem capable of any improvement,
yet few things are really incapable of improvement, and the treatment of
abscesses has undergone many vicissitudes in the past.

It is interesting to trace the history of the treatment of abscesses so far as
this is possible. In most of the early treatises on surgery it was advised that
phlegmons or aposthumes, as abscesses were generally described, should be
treated by the application of sedatives to drive the evil humours out of the
painful part, and by some form of dietary, which varied according to the
fashions of the time and the fancy of the author of the particular treatise.
Later poultices in some form or another were recommended, and the materials
from which these were made included various substances such as cow-dung,
earth, bread, oatmeal and linseed. This treatment by poultices is still un¬
fortunately much too frequently employed in the shape of so-called hot
fomentations, although the modern fomentation, except from the point of
view of cleanliness, compares most unfavourably as regards effectiveness with
the cow-dung poultice of our ancestors.

Even as recently as in the time of our great grandfathers abscesses
were generally treated by freely bleeding the patient and loosening his teeth
with mercury.

From comparatively early times, however, it was recognized by the bolder
spirits in our profession that the best method of all was to make an open¬
ing into the abscess and evacuate the humour, or pus, which it contained,
and with the advent of anaesthetics, which did away with the greatest
objection to this method of treatment, namely, the pain which it involved, it
became a recognized practice, although even at the present time it is not done
as often, or as soon, as it should be.

It was soon recognized that to make an opening only was not sufficient, as
although this at once relieved the more urgent symptoms, the opening tended
to close and the abscess to refill. To overcome this difficulty various foreign
bodies, called drains, were introduced into the wound to prevent its closing
prematurely. Drainage tubes were at first made of pewter for the proletariat

[.February 14, 1923.

66 Lockhart-Mummery: Ischio-rectal and other Abscesses

and silver for the nobility and gentry, gold, I presume, being reserved for
royalty ; but with the advent of democracy india-rubber tubing soon became
universal. At first the tube used to be introduced to the bottom of the abscess,
but it is now generally recognized that it should only just reach the abscess
cavity.

In my student days it was customary to treat abscesses by scraping them out
and packing the cavity with gauze. I have never been able to ascertain who
invented this barbarous practice, or what possible object it was expected to
serve. It resulted in an extremely painful form of dressing, and tended to
delay healing of the abscess to the maximum extent. Quite apart from this it
seems foolish to make an opening into an abscess and then block it up
again. In the case of ischio-rectal abscess, this form of treatment invariably
resulted in producing the most classical kind of fistula-in-ano.

I have for many years been striving to discover a method of treating ischio¬
rectal abscesses by means of which the subsequent formation of a fistula
might be avoided: a fistula was almost invariably the sequel under early
methods of treating these abscesses. I soon found that if a fairly large-bore
drainage tube was stitched into the opening and the end only just allowed to
reach the cavity of the abscess, healing took place in quite a number of cases
without the formation of a fistula. It was difficult, however, to keep the tube
in place, and I have now entirely discarded drainage tubes in favour of the
following method: The abscess is opened with a knife by a crucial incision in
the usual way and the pus allowed to flow out. The skin covering, or forming,
the outer wall of the abscess, is then completely cut away so as to leave a large
opening of an inch or more in diameter, the interior of the abscess being left
entirely alone and untouched. A large flat dressing of moist antiseptic gauze
is applied all over the parts and covered with a protective so as to keep it moist
and prevent it sticking to the edges of the wound and interfering with drainage.
The pad should be large enough to absorb all the discharge for at least twelve
hours. The patient should be nursed lying on his back as much as possible,
so that the pressure is towards the opening in the abscess. When the dressing
is changed it will be found that the abscess cavity has completely vanished,
and that there is only a flat shallow ulcer, which may take ten days or a
fortnight to heal, but does not result in a fistula once in twenty times. I have
seen surprisingly large ischio-rectal abscesses, containing nearly a pint of pus,
heal when drained in this manner without any fistula resulting.

The advantages of this method of draining an abscess are: (l) That it is
supremely simple; (2) that it is not in the least painful, once the opening is
made; and (3) that healing is very rapid and is not followed by a residual
abscess or fistula. It might be thought that very bad scarring would result,
but this is not the case, the ensuing scar being quite flat and surprisingly
small. It is essential that the opening should be amply large, and I have not
hesitated to remove up to a couple of inches of skin in some cases.

I have used the same method in treating abscesses in other parts of the
body with equally satisfactory results, and should now only employ drainage
tubes where the anatomy of the part prohibited the cutting away of the
external wall of the abscess.

Incidentally I may mention that quite recently I have treated an abscess
of the breast in this way, in which a large part of the breast was infiltrated
with pus. A large piece of skin was cut out and no drainage tubes were
used. The wound was completely healed in a little over a fortnight without
any attempt at the formation of a residual abscess, without painful dressings
and with the minimum of scarring.

Section of Surgery

Case which was clinically one of Inoperable Carcinoma of the
Rectum treated by Colostomy and Subsequent Injections
of Cuprase-Collosal Selenium and Collosal Cuprum for
over Two Years, with Disappearance of the Growth.

By Lionel E. C. Norbury, F.R.C.S.

PATIENT, a female, aged 47. Seen by my colleague and myself in the out¬
patient department of St. Mark’s Hospital in October, 1920. Diagnosed as
extensive carcinoma of the rectum, probably inoperable. Extensive growth
within easy reach of the finger but extending up the bowel. Fixed posteriorly.

Symptoms: Constant desire to have bowels opened. Diarrhoea, but no
good result without aperients. Discharge of mucus but no blood.

Admitted to hospital, October 23, 1920, under the care of Sir Charles
Gordon-Watson.

Abdominal exploration, October 28, by Sir Charles Gordon-Watson : Growth
fixed posteriorly ; uterus enlarged ; enlarged mesenteric glands ; liver normal.

Growth considered inoperable. Colostomy performed.

November 8, 1920 : Intramuscular cuprase, 3 c.c. November 11: Intra¬
venous selenium, 5 c.c. November 16 : Intramuscular cuprase, 3 c.c.
November 18: Intravenous selenium, 5 c.c. November 22 : Intramuscular
cuprase, 3 c.c.

November 29 to January 4, 1921: Collosal selenium, 5 c.c., intramuscular,
every seven days.

January 11 to February 28: Collosal cuprum, 3 c.c., and then every
fourteen days until May 24, 1921, and then every twenty-one days until
June 28. Collosal selenium every twenty-one days till September 26, 1922.
Then collosal cuprum every twenty-one days up to the present.

There has been practically no discharge from the rectum for the last
two years and she has steadily put on flesh.

Present state: No growth or ulceration can be seen or felt in the rectum.
Much narrowing of the pelvic colon just beyond the recto-sigmoidal junction,
apparently the result of the colostomy. General health excellent. Vaginal
examination : Nothing abnormal.

Unfortunately no microscopical examination was made of the growth and
so the diagnosis could not be definitely established, but clinically the case is
undoubtedly one of carcinoma.

I have employed colloidal preparations in a large number of cases of
inoperable carcinoma and in my opinion such treatment tends to diminish
the amount of the discharge from the growth and renders it less offensive.

A Specimen of Colon, showing Multiple Perforations
resulting from Dysentery.

Shown by Percival Cole, F.R.C.S.

This specimen was removed post-mortem from a female patient aged 28,
who was taken ill with pain in the lower abdomen and with the frequent
passage of small, liquid, blood-stained stools. She had recently returned from
a holiday on the continent—Germany, Switzerland, France—but this was her
first visit abroad.

Cole: Multiple Perforations

Before admission to hospital, sigmoidoscopy showed soft cedematous,
papillomatous masses protruding into the lumen of the bowel, and commencing
at a distance of 12 cm. from the anus. After admission to hospital the
diarrhoea continued. Temperature ranged between 100° and 103° F.; the pulse
varied from 120 to 160, and the patient's condition steadily became worse.

Emetine was administered hypodermically, although pathologically no
evidence could be obtained to support a diagnosis of dysentery. Ten days
after admission to hospital she became rapidly distended, and began to vomit.

Laparotomy showed that the lower abdomen was filled with a mixture of
fluid faeces and pus, and she died the following day.

The following pathological report has been kindly furnished by Dr. Fry:—

Pathological Report on a. Case of Multiple Perforations of the
Colon, resulting from Dysentery, by Dr. Fry.

(I) Clinical Pathology.

Total leucocyte count, 9,500; polymorphonuclears, 73 per cent. ; large
hyalines, 4 per cent.; lymphocytes, 21 per cent.; eosinophils, 2 per cent.

Faeces : Loose watery stools, tinged with blood with shreds of mucus.
Numerous epithelial cells, a few pus cells, and many red cells. No amoebae,
cysts or flagellates found. No enteric or dysenteric organisms isolated.

Urine: No albumin or sugar. A few urinary epithelial cells. A few red
and white blood cells. Streptococci and Bacillus coli isolated.

Blood : Blood culture sterile. Agglutinations for Bacillus typhosus , Para¬
typhoid A and B, Gaertner, Aertrycke, Shiga, Flexner, V W X Y Z, all negative.

(II) Morbid Pathology (partial post-mortem only).

Peritoneal cavity contained a large amount of brown faBcal exudate and the
intestines were matted together. Omentum drawn down over intestines and
firmly adherent round descending colon. After separation of adhesions faeces
exuded from large intestine, which showed numerous perforations, forming
a lattice work.

Large intestine : Interior of descending colon and sigmoid covered by
a number of plum-coloured masses arising from mucous membrane. The
mucous membrane between the polypoid masses appeared little affected.
Other viscera not examined.

Microscopic sections show a considerable infiltration of the submucosa by
mononuclear cells and oedema of the submucous coat. The mucous membrane,
except where it has sloughed away, is less affected. In the vessels and lacunae
of the submucous coat can be seen a number of relatively large amoeboid
bodies with a well-marked nucleus and nucleolus. They are rather distorted
by fixation but exhibit the general appearance of Amoeba histolytica.

Mr. Percival Cole also showed a Specimen illustrating Vesico-colic
Fistula resulting from Carcinoma of the Pelvic Colon.

Section of Surgeip.

President—Mr. James Berry, F.R.C.S.

The Technique of Resection and Anastomosis of the Colon

for Tumour.

By J. P. Lockhart-Mummery, F.R.C.S.

Considerable improvements have taken place during the last twenty
years in this department of surgery, and it will be useful to revise our
knowledge and practice, and to compare our results in this important field
of abdominal surgery in the light of recent experience.

Resection and anastomosis of the colon has interested surgeons consider¬
ably during the last few years. There was a discussion upon it at the Medical
Society of London on December 6, 1920, and it was one of the subjects dealt
with last September at the Congr&s francais de Chirurgie, in Paris, at which
I was present. 1

Much of our advance in this branch of abdominal surgery has been due to
improved methods of diagnosis. Until comparatively recently stricture and
growths in the colon were seldom detected except when the surgeon was
exploring the abdomen for the cause of acute obstruction. As a result most
of the operations performed were designed to deal with the obstruction
which was present rather than with the tumour itself. Colostomy or Paul’s
operation held the field.

The mortality of resection was high, and anastomosis was generally
performed extraperitoneally by some such operation as Greig Smith’s well-
known method. Even when a definite two-stage operation was planned the
surgeon was invariably handicapped by the presence of a faecal fistula, or
colostomy on the abdominal wall, generally quite close to his operation site,
and this necessarily controlled to a large extent the type of operation which
could be done.

Many of the results were good, but the resections which were possible
under these types of operation were very limited, and infection of the wound
was the rule rather than the exception, so that good results were only
obtained after long and tedious illnesses. Improvement in methods of
diagnosis have altered these conditions, and it may safely be said that now
most tumours of the colon are diagnosed before acute obstruction occurs, or
at least their presence is so strongly suspected that the surgeon is called upon
to explore the abdomen.

The modern surgeon has learnt much of his surgery, and most of his
diagnosis, upon the operating table rather than in the post-mortem room, and

Au—S 1 [May 2, 1923.

70 Lockhart-Mummery: Resection and Anastomosis of Colon

as a result is able to suspect the presence of a tumour in the colon long before
it is palpable, and before serious obstruction has occurred. Aided further by
the sigmoidoscope, by the chemical and microscopical examination of the
stools, and by the use of X-rays after a bismuth meal or enema, a more or less
accurate diagnosis is generally possible.

The fact that the surgeon is now able to operate upon patients with
tumours in the colon before serious obstruction has occurred has entirely
altered the type of operation that is performed, and greatly improved the
results. It will be generally agreed that to attempt to resect or anastomose
the large bowel in a patient suffering from any degree of obstruction is wrong,
and that the proper treatment is first of all to relieve the obstruction and only
to attempt to resect or anastomose the bowel after all obstruction has been
relieved. Further, most surgeons now agree that cases of obstruction in the
large bowel are best treated by draining the caecum.

I would go further, and say that cases of obstruction of the colon should
be treated by simple drainage of the caecum without exploratory laparotomy,
and that the exploratory laparotomy should be postponed until after the
obstruction has been entirely relieved. The adoption of this course does away
with the great danger of exploring the abdomen while the intestines are
distended and the patient is suffering from faecal vomiting.

The simple tube method of performing caecostomy, which was described in
the Lancet (November 25,1922) can be easily performed under local anaesthesia
with the minimum of risk. Within a few days the patient's toxic symptoms
have disappeared and the abdomen can be explored under the best possible
conditions. Caecostomy performed in this way is a clean operation, as every¬
thing drains into a bucket through the tube, and there is consequently no
danger of infecting the wound.

Before an attempt is made to resect the colon, I think it is very important
that the patient should, if possible, be carefully prepared. The bowel should
be cleared out, preferably by the use of castor oil, to which belladonna and
opium should be added to relieve spasm and to enable the aperient to act more
efficiently in the presence of the stricture, which is necessarily present. At
the same time as the castor oil is administered a methylene blue pill, or
teaspoonful of charcoal, should be given by the mouth and a careful note kept
of its first appearance in the stools. This is a rough, but efficient test as to
whether the bowel has really been cleared out. The charcoal should appear
within twenty-four or thirty-six hours; if it fails to do so the bowel should be
further cleared. At the same time kerol, dimol or some other intestinal anti¬
septic should be administered in full doses, or if sufficient time is available, a
good preparation of Bulgarian bacillus may be administered in milk in order to
modify the intestinal flora.

It is necessary to spend some time over the preparation of the patient, and
as soon as the bowels have been satisfactorily cleared the patient should be
put on large doses of liquid petroleum in order to liquefy everything within the
colon and prevent the formation of scybala. During the preparatory treatment
the patient should be fed with ordinary solid food, and on no account should
he be starved. At least a couple of days should intervene between the
administration of the purgatives and the operation. On no account should
the patient be purged just before the operation on the colon. This preli¬
minary treatment is a most important factor in securing good results, and the
expenditure of a week or even more time upon it is fully justified.

Section of Surgery

The Incision.

This must, of course, depend to some extent upon the situation of the
lesion, and it is not always possible to be certain which part of the colon is
affected. The great majority of growths, however, occur in the sigmoid flexure,
descending colon and splenic flexure, the next commonest situation being the
caecum.

For growths on the left side I believe the diagonal incision to be the best.
It should begin close to the midline, li in. above the pubis and be carried
outwards into the angle beneath the last rib (see fig. 1). It is the same
incision, in fact, which is used in exposure of the left ureter. The rectus
sheath is opened up and the rectus muscle itself freed, so that it can be
drawn well over to the right side.

The advantages of this incision are that if the patient is turned slightly on
the right side and is supported with sandbags under the buttock and left
shoulder-blade : (1) It gives splendid exposure to the whole of the left side of

Fig. l.

the colon ; (2) the remainder of the intestines fall away and do not get in
front of the colon during the operation; and (3) practically the whole of the
incision lies through thick muscular structures which readily heal; further (4)
no more that one nerve is likely to be divided ; (5) the results, both as regards
subsequent healing of the wound, and as regards access to the colon, are
admirable ; (6) this incision enables the surgeon to remove the splenic angle
with the greatest ease. When there is doubt as to the locality of the lesion a
midline incision is usually advisable.

The extent of colon removed must vary with the circumstances of the case,
and with the opinion of the surgeon operating, some surgeons preferring
to remove considerable lengths of colon, others preferring merely to remove
that portion which is necessary ; but as a general rule it may be stated that
in the case of a tumour in the caecum, or at the hepatic or splenic
angles, it is better to resect the entire angle rather than to attempt local
resection

72 Lockhart-Mummery: Resection and Anastomosis of Colon

Methods of Joining the Colon after Resection.

Twenty years ago the popular method of joining together two portions of
intestine in order to obtain an anastomosis, was by means of some apparatus
aided by stitching. Murphy’s button, Allingham’s bobbin, Senn’s plates, Mayo-
Robson’s bobbin and Laplace’s forceps all had their advocates, and any surgical
text-book of that time contains numerous illustrations and descriptions of the
various methods of using these appliances.

The most popular instrument was Murphy’s button, which for a long time
held the field owing to the ease with which it could be used. But the
not infrequent fatalities attending its use, the fact that the button was
not always passed but had to be removed by secondary operation, and the
trouble from stricture which often resulted from the small stoma, led to its
disuse.

With increased experience and improved technique surgeons soon found
that plain stitching gave better results both as regards time and subsequent
safety, and no surgeon of the present day would think of using any of these
instruments for the purpose of anastomosing the large bowel.

When stitching first took the place of mechanical appliances lateral anasto¬
mosis was used in preference to axial anastomosis. At the present day we
find that while axial anastomosis is always used in dealing with the small
intestine, from what other surgeons have told me, and from contemporary
writings, it would appear that lateral anastomosis is still the popular method
of joining the large bowel.

The disadvantages of lateral anastomosis are obvious: (l) It requires a much
greater length of bowel. (2) It requires either more extensive freeing of the
colon, or less extensive removal of the diseased part as compared with axial
union. The operation takes much longer to perform, as in addition to the
actual anastomosis two ends of colon have to be closed. (3) The subsequent
anatomical condition is not perfect, and the blind end of the proximal portion
is apt to give trouble. I know of several cases in which there has been an
abscess and ulceration in this portion of the blind bowel. The fact that it is
still popular in spite of these objections shows that there must be some
distinct advantage.

Though actual anastomosis in the small intestine has given universal satis¬
faction, it was found that axial anastomosis in the colon was liable to result in
leakage, and that either peritonitis or faecal fistula resulted. It was supposed
that this was due to the more solid nature of the contents of the colon as com¬
pared with that of the small intestine, the line of suture being liable to give
way from this cause. This, however, is not the real reason. The failure of
axial union of the large intestine has nothing to do with the contents of the
bowel, but is entirely the result of the anatomical arrangement of the blood¬
vessels in the wall of the colon, which differs widely from that of the small
intestine. In the small intestine there is a very free anastomosis between the
vessels feeding the bowel wall. In the colon, however, the arteries pass round
the bowel in a circular direction from the mesenteric side parallel to each other.
There is a free lateral circulation along the marginal artery, but the anastomosis
in the bowel wall is not very free. It is obvious, therefore, that in performing
a resection, if the bowel is cut across transversely and sewn together in this
position, there is considerable risk of the stitches joining the edges of the bowel
on the mesenteric side constricting the vessels, and so damaging the blood
supply of the edge of the bowel opposite to the mesentery. As a matter of

Section of Surgery

fact, when leakage occurs after axial union of the colon it will generally be
found that the leakage is on the side opposite to the mesentery, and is due to
the sloughing of the edges of the bowel where they are stitched together, rather
than to faulty suturing.

In performing lateral anastomosis there is no such danger of damaging
the blood supply, as the arteries themselves cannot be caught up in a suture.
All that is required in order to get a good result in axial union, is to see
that the bowel is cut at an angle of 45° from the mesentery outwards. That
is to say, that a larger amount of bowel is removed on the free than on
the attached side. While this ensures a good blood supply to the whole of the
sutured edge, it has the additional advantage of increasing the lumen of the
bowel at the point of union, and so compensating for the narrowing pro¬
duced by the turning in of the edges through the suturing. If this method
of joining the colon axially is adopted, giving way of the suture line is no
more likely to occur than in lateral anastomosis. I have used this method
for years, and have had very few cases in which the result was not perfect. I
suggest, therefore, that successful anastomosis in the large bowel wholly
depends upon the surgeon ensuring a good blood supply to the joined ends
of the bowel.

Axial Anastomosis.

I do not propose to take up time describing the aseptic technique of
operations upon the colon. Careful protection of all parts of the wound and

Fig. 2.— The dotted lines show how the bowel ends should be divided before
performing end-to-end union. (From 14 Diseases of the Rectum and Colon,” by the
author.) i

of the abdomen by means of swabs and towels is now the universal
practice, so also is that of changing the gloves and instruments after dealing
with the interior of the colon, before closing the wound.

I shall first briefly describe the method I prefer of axial union, and then
other methods, which have their own special advantages and applications.

The part of the colon which it is proposed to resect is first drawn up into
the wound and the mesentery is divided and any vessels secured. Rubber-
covered clamps are next applied well above and below the area which it is
proposed to resect. The bowel is then cut through at an angle of 45° to its

1 For the loan of the blocks illustrating this paper (figs. 2-8b) the author is indebted to
Messrs. BaiUi6re, Tindall and Cox.

74 Lockhart-Mummery: Resection and Anastomosis of Colon

transverse diameter, both above and below and the resected portion is removed,
together with its attached mesentery (fig. 2). If the clamps are controlling
the blood-vessels in the mesentery they should be momentarily released,
particularly the lower clamp, to make certain that there is a good blood
supply to the bowel ends, as it is very easy to damage the blood supply to
the lower ends of the colon when tying off the mesentery, more especially
in fat persons. The two ends of the bowel are then brought in contact and
caught together by two pairs of toothed forceps, or if preferred, guide sutures,
the forceps being applied on the lateral aspects of the bowel, so that the two
mesenteric edges come straight together (fig. 3). If there is excessive bulging
of the mucous membrane some of this may be cut away. A stitch of fine
catgut with a short straight needle is now started from one pair of toothed
forceps and carried across to the other side of the bowel. This stitch takes
up all the coats and is locked about every four or five stitches. It should
be drawn sufficiently tight to ensure controlling any bleeding, and it is just as
well to slack off the clamps occasionally to make sure that this has been done.
When this stitch reaches the opposite pair of forceps they are removed and

Fig. 3.—Shows the application of the forceps or guide sutures at the sides of
the bowel halfway between the mesenteric attachment and the free border. (From
“Diseases of the Rectum and Colon,” by the author.)

it is continued right round until it reaches the point where it started, where
it is tied off (tig. 4). The clamps are then released, the dirty towels and
swabs removed, and the gloves changed, the bowel itself being first of all
gently washed. A fine catgut peritoneal suture is now started on the
mesenteric attachment on the outer side and carried right round the bowel
over the first suture and down the gap in the mesentery so as to close it.
I prefer to use ordinary through-and-through stitches and to use catgut
entirely. Fine catgut on Souttar needles is very good for this purpose (fig. 5).

Lastly I like to have an omental graft over the anastomosis. One great
advantage of the graft is that it prevents the adhesion of other structures to
the line of anastomosis and gives much greater security should there be any
leakage in the neighbourhood of the stitches. I do not think it matters very
much whether it is a live, or a detached, graft. Where the omentum is large
and long a live graft is very satisfactory, but detached grafts appear to me to

Section of Surgery

do equally well and there is not the risk of fixing the omentum and so possibly
of producing bands. Finton and Peet’s experimental work shows that detached
omental grafts remain alive when wrapped round the intestine. I generally
suture the omentum lightly round the junction with catgut sutures and then
divide the omentum afterwards if it is considered necessary. This operation
can be very quickly performed and has given excellent results.

Fig. 4.—When the suture readies the opposite side of the bowel, the toothed forceps
are removed and the stitch is continued around until it reaches the point where it
started. It is then tied off, great care being taken to keep all knots on the inner
surface of the bowel. (From “ Diseases of the Rectum and Colon,” by the author.)

Fig. 5.—Showing the continuation of the fine-thread peritoneal stitch until it
meets the mesentery on the opposite side of the bowel, where it is continued down the
mesentery itself so as to close the gap. (From “ Diseases of the Rectum and Colon,”
by the author.)

For some years now I have made it a practice always to drain the caecum
as a routine in all cases of anastomosis of the colon. I am sure that it renders
the operation much safer, and has been one of the chief means of reducing the
mortality of these operations. I used to use the appendix for this purpose,
but for the last few years have been using the tube method, which as previously
mentioned in this paper, was described in the Lancet (November 25, 1922).

76 Lockhart-Mummery: Resection and Anastomosis of Colon

After the abdomen has been closed a small wound is made over the caecum
and a knuckle of the anterior wall of this organ is pulled out and a puncture is
made into this with a knife. A piece of rubber tube about 8 in. long and £ in.
in diameter is pushed into this opening through the caecum for about 2 in.
Catgut stitches are then passed through the caecal wall and through the
drainage tube in three or four places so as to invaginate a cuff of caecal wall
into the lumen of the caecum itself. A purse-string suture is then passed round
the tube in the caecal wall so as to invaginate the cuff more completely and it is
then tied on to the tube. The caecum is then drawn up against the inner
surface of the abdominal wall, and the abdominal wound stitched up round
the tube (fig. 6). After the patient has returned to bed a long collapsible
rubber tube is attached to the tube in the caecum and its other end passed over
the side of the bed into a bucket. This completely drains the caecum without
anything being soiled, and in practice it is not found necessary to change the
dressings for three or four days. The tube remains tight for about eight to
nine days, and then comes out when the stitches dissolve. As a rule there is
no leakage from the caecum after the tube is removed. This is a much more
convenient method than the performance of ordinary caecostomy, which

FlG. 6.—Tube rwcostomy. (From “ Diseases of the Rectum and Colon,” by the

author.)

invariably causes soiling, and sometimes results in a secondary operation to
close the opening.

There is practically no after-treatment. The bowels can be moved at any
time by giving a mild aperient, and ordinary food can be administered from
the outset.

Other Methods of Axial Union.

Some surgeons prefer to use clamps for sewing the ends of the colon
together, in the same way as in the performance of gastro-enterostomy with
clamps. A very ingenious clamp has been designed by Dr. Abadie, of Paris,
in which the clamp blades revolve on each other in order to facilitate
approximation of the edges of the bowel while passing the posterior stitch.

Methods of performing Anastomosis without exposing the

Mucous Membrane.

Several very ingenious ways of joining the colon together have’ been
designed by means of which the interior of the bowel is neither seen nor
exposed at any time during the operation. Some of these methods deserve
description.

Section of Surgery

The following method was first described by Gudin. The colon, at the
point where it is desired to divide it, is crushed by a powerful pair of crushing
forceps. Four narrow-bladed, tapered forceps are then placed on the crushed
segments of bowel and the colon divided either with a knife or a cautery,
between the clamps. The resected portion of colon with its two clamps
having been removed, the remaining two clamps are brought together, and the
ends of the colon are sewn together with stitches over the clamps, the stitches
taking up the muscular and serous coats only. When the stitch which has
been started at the handle end of the clamps comes back to the same spot
again the clamps are removed and the two ends of the stitch are tied together.
The colon is now joined together, but there is no open lumen as the crushed
ends are still shut. By invaginating the finger into the bowel above the line
of union the lumen can again be re-established.

Fig. 7.—Martel's method of performing anastomosis. 1, ends of colon held in
position by temporary stitch ; 2, anastomosing stitch being inserted ; 3, anastomosing
stitch completed, temporary stitch is now withdrawn. (From “Diseases of the
Kectum and Colon,*’ by the author.)

An ingenious modification of this method has been devised by Martel.
After the colon has been crushed and divided, the clamps are removed and the
two crushed ends of the bowel are placed together one end on the top of
the other. A stitch is then passed through both the crushed ends so as to fix
them together and prevent them getting out of place. The ends of this stitch
are attached to the extremities of a steel bow and fixed (as shown in the
drawing) (fig. 7). The permanent stitch, which of course only takes up the
peritoneal and elastic coats, goes all round the bowel and is tied off. After
this is completed the steel bow is removed and the straight stitch is pulled out.
The lumen of the bowel is subsequently re-established in the same way as in
the previous method.

78 Lockhart-Mummery: Resection and Anastomosis of Colon

A very ingenious clamp has recently been sent me by Dr. Martel which
enables the colon to be joined in a similar manner. There are three small
steel clamps, which fit into a hinge. These are passed over the colon and the
open ends of the clamp are then seized with a specially made handle and
forced together. Small bolts then turn up and hold the steel clamps firmly
together. The handle is now removed, the hinge detached and the centre
clamp is opened and released. The bowel is then burnt through between the
two remaining clamps and a subsequent anastomosis can be done in the same
manner as in either of the previous methods described. This clamp is a most
useful implement, and will certainly save a great deal of time in the resection
of any large portion of the colon, as it can be left attached to the portion
which is to be removed and will obviate the closing of two ends of bowel—
namely, the ends of that portion of bowel which is going to be resected.
I have also found this clamp useful in resecting the rectum.

Fig. 8a.— Method of closing the end of the colon by sewing over a clamp. (From
“ Diseases of the Rectum and Colon,” by the author.)

Lateral Anastomosis.

I do not propose to describe this method of anastomosis, as it is too well-
known, and in my opinion should be given up in favour of axial anastomosis.

Methods of Closing the Ends of the Colon.

This closure is necessary in operations on the large gut, such as colectomy
or hemi-colectomy, abdomino-perineal excision of the rectum, and in lateral
anastomosis. There are several good methods :—

(1) That which I prefer is a Mikulicz stitch of catgut passed backwards and
forwards over a tapered crushing clamp after the bowel has been burnt through.
This stitch, after the clamp has been removed and the ends of the stitch
pulled tight, invaginates the crushed end into the bowel lumen (see figs. 8a
and 8 b). If the ends of the stitch are then tied together further security is
obtained. It can still further be reinforced by a mattress stitch if thought
desirable. This method has the advantage of being simple, and requires
no handling of a septic surface.

Section of Surgery

(2) Another simple method, suggested by Abadie, consists in crushing the
bowel and dividing it, and then seizing the extremities of the crushed end in
two pointed forceps, and rolling the forceps in opposite directions inwards.
A ligature is then placed round the crushed portion and tightened as the
forceps are withdrawn.

(3) Klapp’s method consists in rolling the crushing forceps round so as to
make a sort of Swiss roll of the end of the bowel, and then inserting a few
stitches to prevent the end from unrolling.

(4) There is yet another method—that of crushing the bowel with a tapered
clamp, then sewing round and round the clamp, the clamp being removed before
tightening the stitch. A supporting purse-string suture is certainly desirable
in this latter method, as the crushed portion of bowel is left on the peritoneal
aspect.

When the two ends of the colon are not of the same size, I think the
simplest plan is (a) to slit up the smaller end of the bowel, along its dorsum.

Fig. 8b.—C losure completed by withdrawing the clamp and puUiiig on the ends
of the stitch. The ends are afterwards tightened. (From “Diseases of the Rectum
and Colon,” by the author.)

that is, its free edge, until the two ends are approximately equal in calibre.
Another method ( b ) is that of cutting one end diagonally and one trans¬
versely. This is, in my opinion, objectionable, as the blood supply may be
bad on the side of the transversely divided bowel. Lastly ( c ) there is the
method of anastomosing the two ends and closing up the portion left in the
large end, after the anastomosis is completed.

Anastomosis of Ileum to Large Gut, or Ileo-sigmoidostomy.

This can quite well be done by axial union if the small gut is divided along
its dorsum. The more usual method practised, however, consists in implanting
the small gut into the sides of the large intestine, after closure of the end of the
latter. This is the usual practice in ileo-sigmoidostomy.

So persuaded, however, am I of the importance of the ileocaecal valve in
human beings, more particularly in preserving the anaerobic condition of the
small bowel, that I intend in future, when in the performance of an ileo¬
colic anastomosis, as for instance when resecting the large bowel, to divide the

80 Lockhart-Mummery: Resection and Anastomosis of Colon

caecum itself, and join the caecum to the colon. Such a procedure does not
seem to present any serious difficulties, and will have the advantage of
preserving the ileocaecal valve intact. The advantages of preserving this
valve appear to be more important than the slightly longer time this procedure
may involve.

Anastomosis near the Lower End of the Pelvic Colon.

The resection of a growth situated just above the recto-sigmoidal junction
can be carried out under full use of the Trendelenburg position, and by free
incision of the peritoneum to the outer side of the sigmoid, but considerable
difficulty may be experienced in dealing with the bowel afterwards. Three
possible procedures suggest themselves:—

(1) To close the upper end of the rectum and bring the stump of the sigmoid
out of the abdominal wall as a permanent colostomy. This, while the easiest
and safest method, deprives the patient of the use of a perfectly normal
rectum.

(2) To remove the entire rectum by abdomino-perineal excision and bring
the stump of the sigmoid to the anus. This, while it gives an excellent result,
is a very serious procedure.

(3) To anastomose the ends of the bowel by the tube method. I described
this method in the Lancet in 1908, 1 but subsequently found that Mr. Rutherford
Morison, of Newcastle-upon-Tyne, had previously published a similar method
in some gynaecological reports. It has since been improved upon by Balfour of
the Mayo Clinic, and his modification is certainly the one to adopt in per¬
forming the operation now.

A rubber tube, with an internal diameter of i in. and having a lateral eye
near the end, should be used. After the bowel has been resected, the open
end of the tube is passed into the lower segment of bowel until it can be
reached by an assistant and pulled out of the anus. The assistant then draws
down the tube until the top end is level with the line of division of the bowel.
The upper segment of bowel is now brought down to the lower and a rough
end-to-end anastomosis performed. This completed, the tube is pushed up
the bowel until its upper end with the lateral eye is some 6 to 8 in. above the
line of union. Next, a stout catgut suture is passed through the colon wall
and the rubber tube some 2 in. above the line of union, and tied so as to fix
the bowel firmly to the tube. The tube is then gently drawn down by the
assistant so as to produce a short intussusception. The invagination so
produced should be sufficient to cover the line of junction completely. A few
catgut stitches are inserted to prevent the bowel unrolling. After the abdomen
has been closed the end of the tube is cut off outside the anus and a safety-pin
put through it to prevent its retraction. It is nearly always possible to insert
one or two stitches in order to produce the intussusception necessary. This
operation is much safer if a tube is tied into the caecum at the same time. It
has been performed a considerable number of times, notably in the Mayo
Clinic, where it has given satisfaction.

Total Colectomy.

There is nothing very special about total colectomy to which reference has
not already been made. I believe that in future surgeons will probably
attempt to preserve the ileocaecal valve when it is not involved in the
disease.

1 Lancet , 1908, i, p. 1403.

Section of Surgery

The question as to whether the great omentum should be preserved, or
removed in total colectomy is of some interest. Personally, I have always
removed it with the colon. The fact that my cases of colectomy have so far
been free from subsequent adhesions may possibly be due to this removal.
Certainly, I have seen no bad results, and it is now from five to seven years
since some of the cases were submitted to operation. I cannot argue the
point from the number of cases upon which I have performed this operation,
as they are not numerous enough. It would seem to be of some importance.

Operative Results of End-to-end Anastomosis.

My private case-books show thirty-seven cases of resection of the colon
for tumour with anastomosis. Twenty-three cases have been treated by end-
to-end, or axial, union, with nineteen recoveries and two deaths. One of
these patients died from acute dilatation of the stomach and gastritis due to
the anaesthetic. This is a mortality of about 8 6 per cent. Fourteen cases
were treated by lateral anastomosis, Paul's operation or Greig Smith’s, with
five deaths. I think these figures show clearly enough that axial union is
just as safe as lateral anastomosis.

I may say that the average age of the last eleven patients upon whom
I performed resection and axial union was 66’8 years, so that a mortality of
under 10 per cent, cannot be considered excessive.

The Technique of Axial Anastomosis of the Alimentary Canal.
By Charles A. Pannett, F.R.C.S.

The proper assessment of the relative merits of an end-to-end or lateral
junction of severed bowel is still a subject of controversy, but this does not
concern us here. There are advocates of both methods. Convinced though
we may be that, anyhow in the case of the large intestine, lateral anastomosis
is fraught with less liability to leakage, there are occasions, when, owing to
the fact that sufficient overlapping cannot be attained without tension, axial
suture is forced upon us. It then becomes a very important matter to decide
how this operation shall be performed. The mesenteric angle was always
regarded as a dangerous area by the older surgeons, and, in spite of recent
statements to the contrary, this belief has been substantiated by animal
experimentation. Thus A. L. Soresi, 1 in literally hundreds of experiments,
found that, without exception, an abscess always forms in the mesenteric
angle when an axial suture is performed in the usual fashion. This small
abscess however, usually burrows in the direction of least resistance which
fortunately leads to the lumen of the bowel. The two non-peritonealized
areas do not adhere together as firmly as the rest of the circumference of
the bowel. This difficulty of union is due not only to the absence of the
peritoneal membrane, but also to the almost inevitable interference with
the blood supply at the mesenteric angle by the suture. Skiagrams of opaquely
injected intestine after the performance of end-to-end suture, show that there
is a very abundant vascular anastomosis in the wall of the gut, but just in the
vicinity of the mesenteric angle the blood supply is less free. The anti-

1 Ann. Surg.y 1919, lxix, p. 613.

82 Pannett: Axial Anastomosis of the Alimentary Canal

mesenteric margin of the intestine has the best blood supply, so that there is
no need to cut the ends obliquely from the fear that it will be insufficient
in this area. It was Greig Smith who pointed out that the strongest
adhesions in the abdomen takes place when a peritoneal covered surface
comes in contact with an area devoid of peritoneum. In 1899 it occurred
to J. E. Frazer, 1 therefore, that advantage might be taken of this fact in
intestinal anastomosis. His suggestion was that by rotating slightly the two
cut ends around their own axes in opposite directions, the raw mesenteric
angle of one end would come in contact with a peritoneal covered surface of
the other. He performed the operation upon the dead body. I have acted

Fig. l.

upon this suggestion and have found that both in the small and large intestine
the operation is not only feasible in life, but also a very satisfactory one.

At the site of anastomosis the ends of the bowel are crushed in two large
Kocher’s forceps, so that the lumen is flattened in a plane at right angles to
that of the mesentery, in such a way that when apposed the mesenteric angles
will not be opposite to one another (sec fig. 1). The posterior seromuscular
suture is inserted first. This is important. It is much more difficult to get in
this line of suture properly if the through-and-through stitch is done first
and the seromuscular one afterwards. By cutting along the dotted lines the
clamps are got rid of and the lumen of the bowel opened. Gross soiling of
the area of operation is of course prevented by the usual rubber-covered
clamps applied at a few inches distance away. The through-and-through

1 Lancet , May 13, 1899, p. 128T>.

Section of Surgery

suture is then started as in fig. 2 and carried right round the whole
circumference, after which the seromuscular stitch is completed by continuing
it round the anterior half of the intestine. A few stitches in the mesentery
willfcomplete the anastomosis.

DISCUSSION.

Mr. A. H. BURGESS was pleased that Mr. Lockhart-Mummery had so strongly
emphasized the importance of careful preparation of the bowels for several days at
least before the operation of resection of the colon. If one had the slightest difficulty
in thoroughly clearing out the bowel by laxatives and enemata, or if there were any
degree whatever of obstruction present it was far better to perform a preliminary
eaecostomy ten to fourteen days before the actual resection. He did not think the
explanation offered by Mr. Mummery of the greater difficulty in securing firm union
after end-to-end suture in the colon, as compared with the small intestine, was the
real one, since the vessels coursed tranversely in the wall of the small as well as in that
of the large gut and would run an equal risk of being occluded by the suture near the
mesenteric angle. There were other factors, for example the fluid, rapidly moving, and
the comparatively slightly septic contents of the small gut. The close apposition of the
peritoneal to the muscular coat (except at the mesenteric angle) in the small intestine
was in striking contrast to that in the colon where fat was often present in considerable
amount between the two, not only at the appendices epiploic®, but elsewhere. This
fatty tissue prevented very accurate apposition and did not possess the best of healing
powers. After resection of the colon, therefore, he preferred to close each end and
restore continuity by lateral anastomosis, and he was interested to find that Bevan,
of Chicago, 1 found, both from his own practice and cases collected from the literature,

1 Jovm. Amer. Med. Assoc ., 1920, lxxv, p. 283.

84 Pannett: Axial Anastomosis of the Alimentary Canal

that the mortality after a properly performed side-to-side was only half that after a
properly performed end-to-end anastomosis. He thought some of Mr. Mummery’s
success with his end-to-end union might be ascribed to his present practice of always
performing csecostomy as the concluding step, and thus throwing less strain upon the
line of suture in the colon; this was strongly advocated by Sir Harold Stiles, in his
Presidential Address, before the Edinburgh meeting of the Association of Surgeons, in
1921, and was a most valuable procedure. The really difficult cases were those of
lower sigmoid and recto-sigmoid growths, where, owing mainly to the depth and the
shortness of the lower segment lateral anastomosis was impracticable; here he had
received great help from Balfour’s rubber-tube method. Considerable ingenuity had
recently been expended in devising methods of anastomosis not necessitating exposure
of the lumen of the bowel, some of which Mr. Mummery had mentioned; about twelve
months ago he saw Professor Schoemaker (of The Hague), perform very neatly and
rapidly three such resections of the colon, using his own special forceps. The chief
objection to all these methods, apart from their necessitating the use of very special
appliances, was that one had to trust to the crushing of the bowel wall for the arrest of
haemorrhage (assisted in some of them by cauterization of the crushed portion); there
was no circle of sutures passing through the entire thickness of the wall and securely
controlling the vessels as in the ordinary methods of suture. He knew of one case
where severe, though fortunately not fatal, haemorrhage into the bowel had occurred
from this cause.

Mr. Lockhart-Mummery (in reply) said that he believed axial union would
soon entirely replace lateral anastomosis in resection of the colon. He thought his
mortality figure of 8*6 was the lowest that had yet been published, and it had been
obtained by axial union. He agreed with Mr. Burgess that the routine use of
temporary caecostomy and catgut sutures had a good deal to do with the successful
result. He agreed that the continental method of trusting to crushing for htemostasis.
of the cut edges of the bowel did not appeal to him.

Section of Surflen?.

President— Mr. James Berry, F.R.C.S.

The Sites of Origin and Methods of Growth of Fibro-
adenomata of the Breast.

By Sir G. Lenthal Cheatle, K.C.B., F.R.C.S.

This paper is published in full in the British Journal of Surgery , vol. x,
p. 436 (April, 1923), with the title: “ Hyperplasia of Epithelial and Con¬
nective Tissues in the Breast: its Relation to Fibro-adenomata and other
Pathological Conditions.”

Demonstration on the Immediate Microscopic Diagnosis of
Tumours at the Time of Operation.

By Ernest H. Shaw, M.R.C.P.

Dr. SHAW gave an account of the method he employs, which is described
in full in the Lancet , 1923, i, p. 218. He then proceeded to give a demonstra¬
tion of his method. Fresh tissues for this purpose were provided by Dr.
Bowell, Mr. V. Z. Cope, and by Dr. Shaw himself.

Two Cases of Sarcoma of the Small Intestine.

By Cecil Rowntree, F.R.C.S.

Case I.—Sarcoma of Ileum.

M. K. COMPLAINED of loss of weight and sharp attacks of abdominal pain
and vomiting recurring about once a week, and lasting about twenty-four
hours. No physical signs could be detected, but a barium meal showed delay
in passage through the small bowel.

Operation, May, 1921: A bobbin-shaped growth, 3 in. in length, was found
in the ileum, about 2 ft. from the ileocsecal valve. There were numerous
pale, waxy glands in the mesentery and along the aorta. The growth was
resected, and the patient is still in fairly good health, although only a few
of the glands could be removed.

*.. S-S l

[March 7, 1923.

86 Rowntree: Sarcoma of Small Intestine; Kidd: Sarcoma

Pathological Report .—The portion of small intestine submitted shows an
annular constricting growth, exuberant and ulcerating towards the lumen of
the gut, but not quite completely blocking it. The microscopic section shows
the tissue to be sarcomatous.

Case II.— Sarcomatous Cyst of Jejunum.

A. H. had noticed for a few months only some enlargement of the abdomen
with slight indigestion. The swelling had rapidly increased during the pre¬
ceding forty-eight hours, and had become painful. Examination showed a
cyst about the Bize of a five months’ pregnancy, presumably a twisted ovarian.

Operation, May, 1922 : Laparotomy revealed a large, smooth cyst with
recent omental adhesions. No pedicle could be discovered below, and further
investigation showed that the only attachment was to the jejunum, about 2 ft.
from the duodeno-jejunal flexure. The implicated loop of bowel was resected,
and the patient remains in good health.

Examination of the specimen shows a unilocular thick-walled cyst, filled
with blood-stained fluid, and with many patches of recent blood clot on its wall.
The cyst grows from the antimesenterio wall of the jejunum, and at the point
of attachment, about 1 in. in diameter, is a pale, homogeneous growth projecting
somewhat into the lumen of the bowel, and to a greater extent into the cavity
of the cyst. The histological picture is that of sarcoma.

Case of Large Spindle-celled Sarcoma arising in the Mesentery
of a Coil of Ileum successfully removed at Operation.

By Frank Kidd, M.Ch., F.R.C.S.

HISTORY: Patient, a male, aged 42, examined on November 27, 1922,
stated that four months ago he first began to feel an aching pain in the abdo¬
men just below the umbilicus. Eor the last six weeks the pain bad been con¬
tinuous, and he had noticed that his abdomen had become larger. Dr.
Robertson, of Boston, Lincolnshire, examined him, and thought he could feel
a smooth swelling which he took for a distended bladder. The stream of urine
was unaltered, and there had been no increased frequency of micturition and
no alteration in the character of the urine. The stools had been normal,
showing no evidence of blood, and he had experienced no symptoms of intestinal
obstruction. He had never had venereal diseases nor any other serious
illness.

Examination: The patient had a stout abdominal wall, which rendered
palpation difficult. An indefinite elastic rounded swelling could be felt in the
centre of the abdomen below the umbilicus, which felt like a distended
bladder. The urine was clear and healthy, and passed in a good stream.
Rectal examination did not reveal anything abnormal. The urethroscope
showed that no stricture was present. No evidence could be detected of
disease of the nervous system.

Cystoscopy : A full-sized rubber catheter entered the bladder without
difficulty and drew off 6 oz. of urine. After this manoeuvre the swelling could
still be felt as before. Inspection of the bladder (8 oz. distension) revealed a
healthy bladder wall, no evidence of paresis and pouching, no intravesical
enlargement of the prostate, I could not detect any evidence of tumour

Section of Surgery

pressing into the bladder wall. X-ray examination did not reveal anything
abnormal. I suggested a provisional diagnosis of dermoid of the urachus, or
fibroma of the posterior sheath of the reotus muscle, and advised an early
exploration.

Operation : Exploration was carried out on December 7,1922, under open-
ether anaesthesia. An incision 4 in. in length was made 1 in. to the right of
the middle line below the umbilicus, and the right rectus muscle was turned
outwards. The tumour proved to be a large elastic mass the size of a large
cocoa-nut lying in the mesentery of a coil of ileum. It rested on the pelvic
floor behind the bladder, but had not obtained any adventitious attachment to
the surrounding structures. It was covered with blood-vessels of great size,
mostly veins the size of one’s little finger, running up from the mesenteric
vessels and spreading out over the surface of the tumour. A coil of ileum
was buried in the mass, but was only partially obstructed thereby. It was clear
that the tumour had its origin in the mesentery rather than in the intestine
itself, yet it was obvious that the coil of intestine would need resection if a
proper clearance of malignant tissue was to be effected. The coil of small
intestine with a wedge of mesentery was clamped, and the tumour, with about a
foot of ileum and its included mesentery, was then cut away in one piece.
After ligature of the blood-vessels the lumen of the intestine was restored by
end-to-end suture with an inner layer of catgut and an outer layer of silk, and
the gap in the mesentery closed. A search of the abdomen revealed no other
lesion, so the abnominal wall was closed and the patient returned to bed.
The operation lasted one hour.

Course: The after-treatment consisted of rectal infusion and a single dose
of morphia. There was no shock and the patient rallied quickly. No aperients
were given until the fifth day. By that time the bowels had not acted and the
accumulation of flatus was beginning to be troublesome. The exhibition of
pituitary extract and a turpentine enema brought away a quantity of flatus,
and on the sixth day 5 gr. of calomel were given, followed by an ounce of
castor oil. This resulted in several copious evacuations and from that time
the bowels acted naturally every day and without difficulty. The stitches
were taken out on the twelfth day, the wound being then strapped, and the
patient was allowed up on the fourteenth day. He left the home on the
nineteenth day feeling fit and well, and when heard of recently he had resumed
his occupation and has had no further trouble.

Pathology : The tumour (which was exhibited) proved to be a large spindle-
celled sarcoma arising in the mesentery. Sections were cut and reported upon
by Dr. Fletcher, of 6, Harley Street, as follows: “This large growth
surrounding, but not arising from, the small intestine, has the histological
structure of a large spindle-celled sarcoma. The cells are quite large and in
some places show a tendency to be arranged in bundles. These facts, and
the encapsulation of the growth, suggest that, though malignant, it is not
highly so.”

Comments.

Bounded swellings in the middle of the hypogastrium met with in the male
are usually swellings of the bladder. Any other origin is of rare occurrence.
I have seen a small number of cysts and tumours arising in the urachus, also
fibromata arising from the posterior rectus sheath. I have also seen sarcomata
arising from the prostate or the fat of the cavum Betzii giving rise to such
a swelling. I have also seen chronic abscesses arising from a gland in the
urachal fat.

Kidd: Large Spindle-celled Sarcoma

The question of cystoscopic diagnosis of pelvic tumours is interesting.
It is usually possible to see with the cystoscope a pelvic tumour projecting
into the bladder wall. For instance, it is not at all uncommon to see a
carcinoma of the pelvic colon attached to the bladder on the left superior wall.
In such cases there is also a characteristic appearance of oedema which is
almost specific. I have also seen several cases of diverticulitis of the colon
opening into or projecting into the bladder. In the case of women one can
usually see the projection of the uterus and can often see the smooth projection
of an ovarian cyst. Probably in this case if I had distended the bladder more
fully at the time of inspection I should have seen a smooth projection into the
posterior bladder wall.

As regards the operation itself, it is always helpful when one sees a tumour
surrounded by veins of great size. It usually means one is dealing with a
malignant tumour, and should lead one to carry out a wide resection based
on that fact.

I believe that end-to-end anastomosis is always to be preferred to lateral
anastomosis whenever we are dealing with two sections of gut that are of
more or less similar size. There is a tendency for surgeons to carry out lateral
anastomosis as it is certainly an easier operation to perform, but figures
obtained from statistics at the London Hospital suggest that end-to-end
anastomosis is both a safer operation and also that it leads to far better
functional end-results.

The same figures suggest that it is not wise to give strong aperients after
such an operation, but that it is better to leave the bowel at rest and to its
natural resources and only use purgatives after the lapse at least of four or
five days if no action has occurred naturally before that time.

As regards the origin of the tumour, sarcomata occur in rare instances
in any portion of the small intestine. They occur fairly regularly in the
post mortem room at the London Hospital. They are usually polypoid growths
which project into the lumen of the gut and may lead to intussusception.
From examination of the tumour it is clear that this sarcoma did not arise in
any portion of the wall of the small intestine, nor does it appear to have
originated from a lymphatic gland. The only conclusion at which I can
Arrive is that it must have arisen from the connective tissue in the mesentery
itself.

Section of Surgery

SUB-SECTION OF PROCTOLOGY.

President of Sub-section—Sir Charters Symonds, K.B.E., C.B., M.S.

Patient upon whom an Operation was performed in June, 1920,
for Cancer of the Rectum, by the Abdomino-anal Method.

By Herbert H. Brown, O.B.E., M.D., F.R.C.S.

PATIENT, a male, aged 60, was suffering from an ulcerating carcinoma at
the upper part of the rectum, involving three-quarters of the lumen. It
was thought to be a suitable case for an attempt to be made to retain
sphincter control.

The operation was performed as follows: The patient was placed in the
Trendelenburg position (chloroform anaesthesia). The abdomen was opened in
the middle line, and the bowel divided 6 in. above the peritoneal reflexion on
the rectum. The proximal and distal ends of the colon were inverted and
closed by suture (Moynihan’s method). The lower portion of sigmoid and
rectum was detached as far as could be done from within the abdomen,
keeping close to the sacrum so as to include glands in the mesentery. The
sigmoid was then detached by dividing its mesentery, care being taken to avoid
injuring the vascular supply, until 12 in. were freed.

A tape was tied to the upper end of the distal and lower end of the
proximal portions of the bowel. Both were pushed down as far as possible
into the pelvis. The peritoneum was then sutured to the upper part of the
freed portion of sigmoid colon to close the abdominal cavity, the detached
recto-sigmoid portion being below it in the pelvis, and the abdominal wound
sutured in the usual manner.

The patient was then put in the lithotomy position. The sphincter was
dilated, and the skin round the margin of the anus divided with scissors, the
incision being extended between the external sphincter and the bowel, as in
Whitehead’s operation for haemorrhoids.

The bowel was completely divided with scissors just above the sphincter,
and was then separated with the finger and scissors from the prostate gland
and other tissues. The levator ani muscle was divided between forceps piece
by piece and ligatured, so as completely to free the lower part of the rectum.
This part of the bowel—the rectum and lower 6 in. of sigmoid—was drawn
out through the sphincter, and the sigmoid drawn down by the attached tape
through the sphincter, which was nowhere divided. The closed end was cut
off and the wall of the bowel sewn to the skin round the anal margin.

[April 11, 1923.

Lockhart-Mummery: Early Tabes Dorsalis

The patient suffered from a moderate amount of shock, but made a very
good recovery. He is now, after the lapse of nearly three years, in perfect
* health; he has gained 36 lb. in weight, and sphincter control is quite
satisfactory.

The specimen shows a typical ulcerating adenocarcinoma commencing at
the level of the peritoneal reflexion.

Case of Early Tabes Dorsalis.

By J. P. Lockhart-Mummery, F.R.C.S.

The patient was a man aged 40. Eighteen months before I saw him he
noticed that he had lost complete control over the anus and was liable to have
accidents unexpectedly. This has been getting gradually worse. The bowels
acted regularly, and apart from this he was perfectly normal. No loss of
control over the bladder. No prolapse or bleeding. He was an active man
and lived a normal life. He had not noticed any other symptoms of any kind,
and there was no pain.

On examination: The sphincter appeared normal, and contracted normally.
No piles, and nothing found in rectum. Nerve reactions: Knee-jerks com¬
pletely absent, and pupils did not react to light at all. Examination of skin in
anal region showed there was almost complete loss of sensation in this area for
about 2 in. round the anal orifice. Patient could not feel a prick in this area, but
the sensation to heat was normal. On examining his forearms I found that
there were areas of impaired sensation on the inner side of both forearms
when pricked with a needle, but that the sensation to heat was normal. On
making the patient stand up with his eyes shut and feet together, he swayed
about, but did not fall.

Blood-examination showed a well-marked positive Wassermann reaction,
and on careful inquiry into his history I found that twenty-two years pre¬
viously he had had syphilis, for which he was only treated for ten weeks.

The case was, therefore, clearly one of early tabes dorsalis, but the
symptoms were certainly unusual, and might easily have led to an error in
diagnosis. The case is chiefly of interest from the diagnostic point of view as
illustrating what must be a very rare form of loss of control over the anus.
The loss of control was clearly due to loss of sensation, and not to any
muscular weakness. The patient could walk perfectly well, and had not a
tabetic gait.

Sir CHARTERS Symonds, K.B.E., C.B., M.S., read a paper on “ Nephrostomy
for the Relief of Inoperable Rectovesical Fistula/*

Mr. Donald Armour, C.M.G., F.R.C.S., showed a Case of “ Syphilitic
Disease of the Anus and Rectum in a Young Woman.**

Section of Suv0en>.

SUB-SECTION OF PROCTOLOGY.

President of Sub-section—Sir Charters Symonds, K.B.E., C.B., M.S.

DISCUSSION ON ULCERATIVE COLITIS.

Sir Humphry Bolleston, K.C.B.

The subject of chronic ulcerative colitis, though mentioned in Wilks and
Moxon's “ Lectures on Pathological Anatomy ” in 1875, owes its recognition
in great measure to the writings of Sir William Hale-White, the President of
this Society, who gave the first of his several descriptions of the condition in
1888 [21]. There was a discussion at the Section of Medicine of the Royal
Society of Medicine in 1909 [17] with statistics of 312 cases so diagnosed in
the hospitals with teaching schools in London. In 1911 simultaneous dis¬
cussions on colitis were held at the Harveian Society and at the Chelsea
Clinical Society. It is a disease on which British physicians have made the
great bulk of the contributions. The question naturally arises whether, in the
years since these discussions, any important advance in our knowledge has been
made. From the bacteriological and medical points of view it must be
admitted that there is little to say. From the diagnostic standpoint the
increasing appeal to the sigmoidoscope is important, and as regards treatment,
the increasing stress laid on the value of appendicostomy is the most noticeable
feature.

Scope of the Term .

In introducing a discussion it is important to define its scope, and in this
instance it is somewhat difficult to limit the field. By a process of exclusion,
some idea may be arrived at; it will be agreed that many forms of ulceration
of the colon may be eliminated as not coming within the meaning of ulcerative
colitis. Thus exogenous ulceration due to an abscess rupturing into the bowel,
e.g., an appendix abscess, malignant ulceration, stercoral ulceration, diverti¬
culitis, typhoid and paratyphoid, “uraemic ” and tuberculous ulceration, bacil¬
lary and amoebic dysentery may be counted out. Ulceration due to acute
colitis of known toxic origin, such as that due to corrosive sublimate poisoning,
and the various forms of parasitic colitis and of infective proctitis of local
origin and extent should not be included in ulcerative colitis. The ulceration
exceptionally found in pneumonia and after accidents (those causing paraplegia
having suggested a trophic disturbance) should also be excluded. A few words
should be added about what was formerly known in this country as the
ulcerative colitis of asylums, and in America as institutional dysentery. Early

[May 9, 1923.

Kolleston: Discussion on Ulcerative Colitis

in this century Vedder and Duval (1902) [20] in America, and in this country
Mott and Durham (1901) [14] and Eyre (1904) [3], showed that it was bacil¬
lary dysentery, thus confirming Gemmel’s view (1898) [5]. Sir Frederick Mott
has most kindly provided me with information as to the present position of
knowledge of this disease in the London County Council Asylums: since the
term “ colitis ” and the idea that it was a non-infectious disease due to trophic
changes have been given up, the type of disease has altered so that severe and
acute cases are less frequent. Outbreaks are almost certainly due to the
presence of chronic carriers, and his assistant, Captain A. S. Mann, who has
done much serological work on the subject, finds that the responsible organism
is Type X of the Oxford series of Flexner dysentery organisms. It appears
advisable to exclude from the group of cases that may for convenience be called
ulcerative colitis, the cases often arising in epidemic forms in asylums, and to
confine our attention to the sporadic cases seen in the ordinary civil practice
which are not, from a laboratory point of investigation, bacillary dysentery.

Bacteriologically, ulcerative colitis is not a specific disease, for numerous
organisms, Bacillus coli t coliform organisms, Bacillus pyocyaneus , pneumo¬
cocci, and streptococci may appear to be the predominating and causal agents.
A bacteriological diagnosis is comparatively easy in the acute stage, difficult
when the condition has become chronic. The opportunities for secondary
infection in the colon are most favourable, and it is probable that ulceration of
the colon, originally due to one micro-organism, may be kept up by the com¬
bined attack of different bacteria, or to successive varieties or strains of pyogenic
cocci. Lockhart-Mummery in 1911 [10] drew attention to the gravity of
cases of ulcerative colitis following tropical dysentery in which the original
infection has died out. It is indeed difficult to be certain that the original
infection has entirely disappeared ; for although the stools may not give any
evidence of amoebic or bacillary dysentery, the organism may still be present in
the walls of the colon. Dr. J. W. McNee has shown me a specimen of the
colon with Entamoeba histolytica in the blood-vessels from a man who had never
been out of England and presented the symptoms of ulcerative colitis with
absence of Entamoeba histolytica from the stools. It is not surprising that in
such cases specific treatment, for example, emetine for latent amoebiasis, may
fail to be curative, just as iodides may prove disappointing in an actinomycotic
lesion with secondary streptococcic invasion. Further, ulceration of the colon
is often a stage in an acute or chronic inflammation of the bowel, and not, as
far as is known, a process due to the advent of a special micro-organism. The
acute phase, as in haemorrhagic colitis, may pass off or prove fatal before
ulceration is established (vide Grant [6]). It must indeed be admitted that
ulcerative colitis is not a disease in the strict sense of the word, any more than
rhinitis or bronchitis is, but that it is a syndrome with fairly constant
clinical manifestations and anatomical changes, which may be excited by
different factors.

JEtiology.

As the causes favouring infection of the colon and widespread ulceration
are obscure, reference may be made to McCarrisOn’s [13] and Findlay’s [4]
observations showing that a devitamized diet renders animals less resistant to
infection ; thus, McCarrison found that healthy monkeys, carriers of Entamoeba
histolytica , may, as the result of a deficient diet, develop amoebic dysentery,
and in an infected area organisms of the hog cholera group attack pigeons on a
devitamized diet and spare those properly fed. Diminution or deprivation of

Section of Surgery: Sub-section of Proctology 93

the water-soluble vitamin B, such as occurs in food consisting of excess of starch
and fats, favours infection. The whole alimentary tract of the experimental
animals shows atrophy and necrosis; and acute colitis, but not ulcerative colitis,
was described. It is, however, easy to understand that in man a diet deficient
in protein and water-soluble vitamin B might so reduce the healthy resistance
of the mucous membrane of the colon that micro-organisms previously harmless,
such as Bacillus coli t would become pathogenic; in short, the carrier would
become a patient. It is also conceivable that changes in the mucous membrane
of the colon may so alter their environment that bacteria unable to multiply
in ordinary conditions would grow without inhibition, in other words, that the
intestinal flora would change. Bassler [l] speaks of a coliform organism of
enhanced virulence as the Bacillus pseudodysentericus coli . Nearly thirty years
ago the late Leopold Hudson [8] suggested that swine fever and ulcerative
colitis might be identical, and quoted a few instances in which the disease had
followed the consumption of pork. He also pointed out similarities between the
morbid lesions and the clinical manifestations in the two diseases. Professor
F. Hobday tells me that no definite proof has as yet been brought forward
in support of any connexion between these human and swine diseases.

Complications.

Is the incidence of perforation lower now than it was formerly in this
country ? Among sixteen cases selected from those recorded in the Transactions
of the Pathological Society of London (1885-1907) it occurred in five, and out
of thirty-three fatal cases (probably including the above) collected in 1910 by
Lockhart-Mummery [10], nine showed perforation and general peritonitis;
possibly some of the cases were published on this account; or has the type of
the disease changed either from alteration in treatment or from less obvious
causes ? Among twenty-two selected cases of ulcerative colitis examined after
death at St. George's Hospital between 1890 and 1922, MissN. Schuster found
four cases of perforation, two being in the “ nineties '' and two during the war;
so far as this small group goes there does not appear to be any special alteration
in the incidence of perforation. In very rare instances perforation is found
after death, with but little evidence of peritoneal response, and it is probable
that the perforation was an agonal phenomenon when the reactive powers of
the body were reduced to a minimum. Multiple perforations have been very
rare. At the Mayo Clinic, Logan [11] found that among 117 cases of chronic
ulcerative colitis, which appear to have mainly followed dysentery, perforation
was not uncommon and was a cause of localized abscess and not necessarily of
general peritonitis. Hurst [9], on the other hand, found that localized abscess
is exceptional and general peritonitis very rare, and that the latter when present
is due to direct spread of infection through the walls of the colon and not to
perforation. He states that stricture from cicatrization of the healing ulcers
never occurs, and other experience in this country supports this conclusion ;
among the sixteen selected cases from the Pathological Society there was one
only in which any mention of narrowing is made; in that case the descend¬
ing colon was described as much contracted and thickened ; no stricture was
found among the twenty-two cases analysed by Miss Schuster; Logan [11],
however, definitely states that stricture is likely to occur. Possibly the nature
of the Mayo Clinic cases are not exactly the same as of those in this country.
Arthritis, well recognized in bacillary dysentery, also occurs in a small percentage
of cases of ulcerative colitis. Among Yeomans' [22] sixty-five cases arthritis
or joint pains were noted in four. Peripheral neuritis has also been recorded.
Ulceration in the small intestine is most exceptional.

Kolleston: Discussion on Ulcerative Colitis

Clinical Features .

The sexes are equally affected, and the incidence falls chiefly on young
adults and in early middle life; among Logan's 117 chronic cases sixty-five
were under 30 years of age, and only eight over 50. The onset may be sudden
or insidious, and the course of the illness also acute or chronic. Acute colitis
due to one micro-organism, such as the pneumococcus or streptococcus, or
dysentery bacillus, may be succeeded by a chronic infection by a different
bacterium. The first symptoms are usually those of colonic irritation—frequent
stools, sometimes preceded by constipation. In the acute cases the tempera¬
ture is raised; in chronic cases it is normal or even subnormal, except for
elevations corresponding to exacerbations. The leucocyte count appears to
vary; in some instances there is a leucocytosis, in others it is absent. As
would appear probable (Price-Jones [16]), on the assumption that there is a
coliform infection, a lymphocytic increase has been reported (Horder, quoted
by Hurst [9]); but the blood picture would naturally differ with exacerbations
and intermissions in the chronic form. Anasmia with 50 or even 20 per cent,
of haemoglobin is partly due to loss of blood, partly to toxins absorbed from
the colon. The number of stools varies from three to over twenty in the
twenty-four hours, but sometimes there are periods of constipation. The
number of evacuations are less than in tropical dysentery, and tenesmus, which
depends on the presence of ulceration low down in the rectum, is inconstant; it
occurred in one-third of Logan’s cases [11]. The excreta contain blood, pus,
mucus, and sometimes sloughs of the mucous membrane. Onset with haemor¬
rhage has been correlated with the commencement of ulceration low down in
the colon (Hawkins [7]). Abdominal discomfort is commoner than actual
pain, the latter chiefly occurring before the bowels act or when there is much
flatulence; local tenderness on deep pressure over the colon is variable. The
importance of a sigmoidoscopic examination does not at the present day need
emphasis ; though it only provides information about part of the large intestine,
that portion generally shows ulceration if it is present anywhere. The ulcers
are indistinguishable from those of bacillary dysentery. Logan [11] gives a
number of skiagrams showing interference with the peristaltic waves, which
become lengthened, more superficial, with rounded instead of sharp edges, so
that eventually the fibrosed colon appears as a thick-walled tube without
haustrations, often with stenosis. Hurst [9] describes mottling of the colon,
which is often abnormally narrow from spasm. Appetite and digestion are
fairly maintained, but loss of weight and weakness are induced by the diarrhcsa
and toxaemia. The mortality is high, about 50 per cent., and Lockhart-
Mummery [10] estimates that it reaches 78 per cent, when treated medically.
The cases are prone to relapse. The chronic cases must be diagnosed from
carcinoma, tuberculous and follicular ulceration of the colon, the sigmoidoscope
being the obvious means of so doing.

Treatment .

Many methods of treatment have been employed.

Dietetic .—As the stomach and small intestine are practically always free
from ulceration, and as digestion and absorption are fairly well carried on, it is
unnecessary to restrict the diet to slops and soft food. As deficiency in the
antiscorbutic vitamin C has been shown experimentally to reduce the resistance
to infection (G. M. Findlay [4]) ; and as McCarrison’s [13] observations
suggest that lack of water-soluble vitamin B favours the incidence of inflam-

Section of Surgery: Sub-section of Proctology

mation of the alimentary canal, it would appear reasonable to arrange a diet
containing a sufficiency of antiscorbutic food and a fair quantity of protein.
Soured milk with living cultures of Bacillus bulgaricus has naturally been
given a trial, but Hurst [9] did not find that it had any beneficial effect.

Drugs .—The large number of drugs employed is in itself a reproach to
purely medical treatment. Intestinal antiseptics, such as salol, bismuth
salicylate, £-naphthol, small doses of mercury or calomel, benzyl benzoate,
gentian-violet, acriflavine, are on the whole disappointing. Pomegranate bark
and simaruba have also been tried; and more recently Logan [11] remarks of
kaolin that it “ was of no benefit whatever, although it is advised strongly
by German writers.” Finely pounded charcoal has been useful in reducing
flatulence and obviating colic. Liquid paraffin by the mouth has been recom¬
mended as forming in the colon a coating in which bacteria cannot live (C. J.
Macalister [12]); and olive oil has been advocated both orally and by enemas
(Logan). Lavage of the colon with antiseptics, such as boric acid, acetozone,
argyrol, nitrate of silver, albargin (silver nucleinate), allantoin, emulsion of
sulphur, has been much employed; but, as the whole of the colon cannot be
thus satisfactorily cleaned, appendicostomy or caecostomy has largely super¬
seded rectal injections as an effective means of washing out the colon.
Einhorn employs a “jointed intestinal tube” 15 to 20 ft. in length introduced
by the mouth and carried, under the guidance of X-rays, into the caecum,
where it is left in situ for days as a means for getting a result comparable to
that of caecostomy; this procedure is on its trial. The respective merits of
appendicostomy and caecostomy have been much discussed ; when the appendix
is obliterated, or, for other reasons, cannot be found, a valvular caecostomy can
be made; but neither this procedure nor appendicostomy gives the colon that
rest from the contact of faeces which is insured by an open caecostomy or a
colotomy. In 1911 Sir D’Arcy Power [15] took the cautious view that the
improvement after appendicostomy was mainly due to the prevention of toxic
absorption and keeping the bowel clean, and stated that the ulcerative process
continues until the patient becomes naturally or artificially immune (by means
of vaccine). Hurst considers that appendicostomy halves the time of illness
that would be experienced under medical treatment, and surgical opinion is
strongly in its favour. To give operation a fair chance it should be done before
the patient is debilitated, and according to W. G. Spencer [18] medical treat¬
ment should not be persisted in for more than three months. Short-circuiting
the ileum into the pelvic colon has the serious drawback that the rectum is
often affected; the radical means of providing physiological rest to the colon
is a complete transverse ileostomy so as to exclude the colon; Stone [19]
recommends this in combination with a separate appendicostomy for irrigation
of the colon.

Vaccines have been extensively employed; few reports are enthusiastic, and
the difficulty of obtaining the causal organism is considerable, even with the
help of serological reactions. An autogenous Bacillus coli or coliform vaccine
has usually been employed; but should not be given during the acute acerbations
of this chronic infection, as the condition may thus be seriously aggravated.
In 1909 H. P. Hawkins [7] advocated anti-dysenteric serum, especially in
acute cases, but without giving any statistics as to its value. In 1921 Hurst
[9] recorded very striking results from the intravenous injection of multivalent
anti-dysenteric serum in two patients who did not show dysenteric bacilli in
their faeces. The healing of the ulcers as watched by the sigmoidoscope
occurred in one of the cases in five days after the first injection of serum, and

Horder: Discussion on Ulcerative Colitis

as the blood did not agglutinate any stock dysenteric organism, the question
arises how far the curative action was due to the horse serum apart from its
specific anti-dysenteric content.

REFERENCES.

rl [1] Bassler, A., Med. Bee ., New York, 1922, ci,p. 227. [21 Einhorn, M., Amer. Joum. Med.

Sci., Philad., 1921, cixi, p. 646. [8] Eyre, J. W. EL, Brit. Med. Joum., 1904, ii, p. 1002. [4]

Findlay, G. M., Joum. Path, and Bacteriol., Edin, 1923, xxvi, p. 1. [6] Gemmel, “Idiopathic

Ulcerative Colitis (Dysenteiy),” Baillidre, Tindall and Cox, 1898. [6] Grant, J. W. G., Brit. Med.

Joum ., 1928, i, p. 308. [7] Hawkins, H. P. f Ibid., 1909, i, p. 765. [8] Hudson, L., Trans. Path.

Soc., 1896, xlvi, p. 834. [9] Hurst, A. F., Guy's Hosp. Repts., 1921, lxxi, p. 26. [10] Lockhabt-

Mummery, P., “ Diseases of the Colon,” 1910; Brit. Med. Joum., 1910, ii, p. 948; Ibid., 1911, ii,
p. 1685; Ibid., 1920, i, p. 497. [11] Logan, A. H., “ Collected Papers of Mayo Clinic,” 1918, x,

p. 180. [12] Macalister, C. J., Brit. Med. Joum., 1912, i, p. 371. [18] McCarrison, R ;j

“ Studies in Deficiency Disease,” 1921, Oxford Medical Publications; Brit. Med. Joum., 1920, i,
pp. 249, 822. [14] Mott and Durham, Report on Colitis or Asylum Dysentery, 1901. [15] Power,

D’Arcy, Brit. Med. Journ., 1911, i, p. 863. [16] Price-Jones, C., “ Blood Pictures,” 1917, p. 46.

[17] Proc. Roy. Soc. Med., 1909, ii (Sect. Med.), pp. 69-166. T18] Spencer, W. G., Med. Science

Bond., 1919, i, p. 22. [19] Stone, H. B., Ann. Surg ., 1923, Ixxvii, p. 293. [20] Veddeb and

Duval, Joum. Exper. Med., New York, 1902, vi, p. 181. [21] White, W. Hale, Guy's Hosp.

Repts., 1888, xlv, p. 131. [22] Yeomans/F. C., Joum. Amer. Med. Assoc., 1921, lxxvii, p. 2043.

Sir Thomas Horder.

I may have made more dogmatic statements with regard to this condition
ten years ago. In my experience ulcerative colitis is found more commonly in
women. Of ten recent cases in private practice eight were in the female sex ;
of five hospital cases only one was a male. The disease favours young middle
age, 25 to 35. Among setiological factors I would mention enteroptosis,
circulatory factors, and infections. Some of the patients are found to have
a cardiac lesion dating from a previous infection. With regard to bacteriology
I would say that streptococcal infection—not only Streptococcus faecalis or
viridans but also long-chained streptococci—should come first, with the colon
bacillus much later. Certain clinical points deserve mention. There is often
an intense degree of anaemia. The spleen is sometimes enlarged, and this
may be due to an infarct that does not suppurate. The liver may be
enlarged. In one case in which I had the opportunity of seeing this organ
during caecostomy it was pale and fatty and reached nearly to the umbilicus.
Within two months of the operation it went back to its normal level. Ulcer¬
ative colitis has a great tendency to recur. The doctor is often consulted
after there have already been several attacks. Quite a number of people
having normal-looking stools suffer from chronic ulceration. When the
physician thinks he has cured the patient and has examined by means of the
sigmoidoscope, quite frequently there are still many ulcers present. What
determines the recurrences which are such a marked feature in the disease ?
I think that ulcerative colitis is not so much a disease of the colon as a
disease of the patient. It is a disease largely due to low resistance, just as are
phthisis and malignant endocarditis. With regard to treatment, if the patient
be in such a condition that operative treatment must be tried, the colon maybe
drained by an appendicostomy or a caecostomy. If this has already been done
I recommend treatment as for pulmonary tuberculosis, in bed, and in the open
air. The diet should be the fullest that the patient can comfortably manage
without increasing the diarrhoea. A milk diet does not, in my experience, suit
these patients. Tonics are useful. Vaccines may be used as supplementary
treatment, but I do not rely upon them. To sum up, as stated, the disease
is one of low resistance, the most common infection being steptococcal.

Section of Surgery: Sub-section of Proctology 97

General methods of treatment should be adopted, supplemented perhaps by
appendicostomy. There must be a long convalescence; for three months after
the patient is up and about there should be no return to work.

Mr. J. P. Lockhart-Mummery.

The last general discussion on ulcerative colitis took place here in 1909,
and the figures produced at that meeting showed that not only was the disease
by no means as rare as was supposed, but that it had a mortality of over 50
per cent. Undoubtedly great improvements have taken place during the last
fifteen years, and thanks to the improved methods of diagnosis and treatment
the mortality has been greatly reduced. My own most recent figures show
a mortality of only 15*7 per cent.

We have to bear in mind that ulceration of the colon, like ulceration of the
skin, may occur in a great many different forms and arise from a great many
different conditions. The actual amount of ulceration may be slight and
confined to a small area, or, on the other hand, it may be so extensive as to
involve the entire colon, a surface very nearly equal to half the area of the
body surface. The ulceration may be quite superficial, or again it may be so
severe that only a few islands of mucous membrane are left. Also, we may
see it at different stages.

A careful study of the disease, now extending over a considerable number
of years, leads me to believe that ulcerative colitis starts in most cases in the
solitary follicles and spreads from these. In the very early stages of ulcerative
colitis one finds small punched-out ulcers which are evidently due to the
breaking down of these follicles. Later on this characteristic disappears and
the ulcers tend to run together and to become irregular in outline. In very
acute cases the whole of the mucous membrane appears to be acutely inflamed
with enormous ulcers in the more prominent parts.

A great deal of interest naturally attaches to the mode of infection, and
while in some cases this is comparatively clear, in others it is decidedly
obscure. Cases of ulcerative colitis occurring in lunatic asylums under the
name of “ asylum dysentery ” are probably an infective disease from some
specific organism and due in the main to bad hygiene. The ulcerative colitis
that follows Bright’s disease, lead and mercurial poisoning, &c., hardly comes
within the scope of our inquiry, though it is none the less important. Con¬
siderable interest attaches to those cases in which chronic ulcerative colitis
is grafted on to acute epidemic forms of ulceration, as for instance where it
follows amoebic or bacillary dysentery, or sand dysentery. Many of these cases
were seen during and after the War, and as regards both their behaviour and
appearance they differed little from the ordinary cases of ulcerative colitis.
No doubt what had happened was that the ulcers produced by the amoebae
became secondarily infective, and after the amoebae had entirely disappeared an
ordinary streptococcic infected ulceration was left. It seems very probable
in very many cases chronic ulcerative colitis is due to secondary infection of
a more acute condition. A good instance of this came within my notice
about a year ago.

The patient was a man, about 30 years of age, who had had slight attacks of colitis
for some time, but never severe. During one of these attacks he was given milk
which was badly contaminated with streptococci. Several other people were made
ill by this milk which was eventually traced to a cow with an ulcerated udder. As a
result he became exceedingly ill with a very severe type of ulcerative colitis and nearly
died. There could be little doubt in this case that the severe condition was due to the
secondary infection.

98 Lockhart-Mummery: Discussion on Ulcerative Colitis

We are still very much in the dark as to the exact bacteriology of this
disease. Great difficulty arises from the very large number of organisms
which are found in any specimen taken from the stools. There is no exact
means of ascertaining which is the controlling organism or organisms. Just
lately a good deal of work has been done at St. Mark’s Hospital, and by Dr.
Carnegie Dickson, on some of my cases, and an organism belonging to the
paratyphoid group has been found to be present in quite a number of instances,
sometimes associated with streptococci and staphylococci, and sometimes
without. We are hoping that this may prove to be one of the controlling
organisms, but this side of the subject I shall leave to be discussed by the
bacteriologists, except to say that so far we have found that the best results
are obtained by an appendicostomy combined with attempts to substitute
another organism. The one most frequently used being the Bulgarian
bacillus. We had hoped that it would be quite easy by putting pure cultures
of the substituted organism into the colon direct to replace the infecting one.
This, however, has not proved easy. The replacing organism is very apt to
die out unless administered in very large quantities, and unless fed with
suitable substances. We have, however, had some success already with this
method of replacement and I believe it has great possibilities, but so far our
knowledge of this subject is only in the very early stages. Careful bacterio¬
logical tests have to be made and checked, and we have yet to learn how to
replace the streptococci and staphylococci which unfortunately are the most
serious infective agents. In my experience vaccine therapy has not proved
of much value, but I believe that good results will be obtained by the
replacement of the infecting by some harmless organisms r when the technique
of this procedure has been perfected.

The most serious cases of ulcerative colitis appear to be those due to a
streptococcic infection, but as already stated, probably the streptococcus
is not the primary organism. Staphylococci are also frequently found
to be present in considerable numbers. A very interesting type is that in
which the Diplococcus pneumoniae is the primary organism. I have met with
two of these cases, in both Diplococcus pneumoniae was present in almost
pure culture ; both cases were acute and accompanied by profuse bleeding and
high temperature. In neither case was there any infection of the lung or any
other part of the body.

The disease is one of early adult life. The average age of the first series of
sixty cases that I collected was 37; while in my last series the average age
was 32. The sexes appear to be about equally affected.

The leading symptom is diarrhoea, which is severe and persistent. Bleeding
is almost invariably present and may be profuse so that the patients become
distinctly anaemic. Wasting is usually rapid and severe. With the exception
of the pneumonic cases the temperature is not generally high, the ordinary
temperature ranging from 99° to 101° F. In cases that end fatally the patients
usually die from exhaustion, perforation or haemorrhage; exhaustion and
wasting being the commonest cause of death.

Diagnosis of ulcerative colitis should in these days present no difficulty, all
that is necessary being an examination with the sigmoidoscope. It should be
insisted upon, however, that no diagnosis that is not based on an examination
of the bowel with the sigmoidoscope can be relied upon.

The actual type of ulceration seen varies enormously. No diagnosis can
be considered complete without a careful examination of the stools by a
thoroughly expert bacteriologist, as it is very important to know what type
of infection we have to deal with.

Section of Surgery: Subsection of Proctology 99

Natural Healing of Ulcers .

By watching cases of ulcerative colitis with the sigmoidoscope from time
to time one is able to see the ulcers during the healing stage, and it is a very
striking fact that although most extensive ulceration may have been present
healing occurs often without a trace of scarring being left, except in a
few cases. Where the ulceration has been severe slight scarring may
sometimes be seen. Only recently I saw a case in which the mucous
membrane still showed small shallow healed pockets, the result of healing
ulcers. I have, however, seen quite large ulcers, which appear to go down
to the muscular coat, disappear without leaving behind any obvious scarring.

It is certainly a fact that stricture of the colon secondary to ulcerative
colitis, although not unknown, is a very rare condition. Stricture after
ulceration is more likely to occur where caecostomy or colostomy has been
performed, and one of the great objections to these operations in cases of
severe ulcerative colitis is that severe stricture may result below the colostomy
and prevent the possibility of re-establishing the bowel if the ulceration is
healed up. This objection, however, does not apply to appendicostomy.

Prognosis .

The prognosis in oases of ulcerative colitis is distinctly bad, apart from
operation. The mortality in operated cases was shown, in the last discussion
which took place on this subject, to be over 50 per cent.: now it is only
a little over 15 per cent., a reduction of 35 per cent.

In non-operative treatment recovery, even when it occurs, is very slow, and
I have seen several cases treated without operation in which the patients have
ultimately had to have an appendicostomy performed upon them, and it would
have been much better if they had undergone it at the beginning.

In these days the prognosis is quite good provided an appendicostomy is
performed early, but a great deal depends upon not leaving the operation until
too late; once a really extensive ulceration has occurred and the patient has
got badly run down in health the prognosis is not nearly so good. Nearly all
the fatal cases in my series were those in which the patient did not come
under the surgeon until he was almost in extremis .

There are two forms of operation for this condition :—

(1) Giving rest to the Colon by the Establishment of an Artificial Anus .—
This method, while yielding good results, is open to serious objections. The
disease practically always involves the entire colon and therefore a caecostomy
will be necessary. A caecostomy is a very unpleasant form of artificial opening,
and in addition it considerably interferes with the patient's digestion. The
other serious objection is that it may prove impossible to close the opening
owing to the contraction of the bowel below. The only cases of stricture of
the colon following ulcerative colitis which have come under my observation
have been those in which a caecostomy had been done, which would make it
appear that in a non-functioning colon secondary contraction is liable to occur.

(2) Making an Opening through which the Colon can be irrigated — namely ,
Appendicostomy .—One of the great advantages of appendicostomy is that the
operation can quite easily be performed under local anaesthesia and consequently
is not contra-indicated by the illness of the patient. It is, however, very
advisable that the appendicostomy, if possible, should not be opened until the
small wound in the abdominal wall is completely healed, or infection with
organisms from the inside of the colon is certain to occur and may give rise to

100 Lockhart-Mummery—Carnegie Dickson: Ulcerative Colitis

considerable trouble. It might be thought that if good results arise from
appendicostomy, irrigation from below will be equally effectual, but this is not
the case. The attempt to introduce large enemata into an irritated colon
produces violent tenesmus and has to be abandoned. There is no such
objection to fluids run in at the other end of the colon.

There are one or two points of considerable importance in treating cases by
appendicostomy. A catheter should not be tied into the appendix if it can
possibly be helped, as it is very liable to give rise to sloughing of the appendix.
A catheter should only be passed when the irrigation is being performed.
A properly performed appendicostomy will remain patent indefinitely and no
leakage occurs from the opening. It causes quite the minimum of inconvenience
and the bowel can be washed through very easily by the patient himself.

I think it is very important that the solutions used for irrigating the colon
should be as nearly as possible at blood temperature, and an accurate
thermometer should be used for making certain of this. The best fluids to use
are hypertonic solutions, so that the tendency is for the fluid to run into the
blood, rather than for fluid to be drawn from the blood into the colon. No
poisonous solutions should be used, as poisoning is very easily produced if
antiseptics are used in the colon.

Of all the different solutions I have found the best results follow the use of
a hypertonic solution of sea salt. Why sea salt should act better than
ordinary salt I do not know, but it certainly appears to do so. Weak silver
solutions such as protargol or argyrol are useful in some cases. Silver nitrate,
however, should not be used as it is liable to give rise to argyria. When
haemorrhage is a marked feature a solution of kaolin is often very effectual
in checking the haemorrhage. As already mentioned we have been using
sour milk containing Bulgarian bacillus for the purpose of washing out the
bowel, and I believe there is a distinct future for this method of treatment
when we have learnt rather more about it. Solutions containing oil or
petroleum are also distinctly useful in protecting the ulcers during the healing
stage.

Recurrences .—The bowel should, as a rule, be washed out twice a day, or
even more often in bad cases, the important point being to keep the ulcers
as clean as possible and prevent the discharges from accumulating in the colon.

To sum up, I believe that the mortality of ulcerative colitis has been very
greatly reduced by appendicostomy, but this operation should be performed as
early as possible, as soon as a definite diagnosis has been made by means
of the sigmoidoscope. Operation can be perfectly well performed under local
anaesthesia without endangering the patient’s life. Everything depends upon
early treatment and the fatal cases are nearly always those in which operation
has been postponed.

Dr. W. E. Carnegie Dickson.

From the point of view of the pathologist and bacteriologist, it is no easy
matter to focus in one’s mind a distinct entity or definite disease that can be
specifically termed 44 ulcerative colitis ” ; just as one cannot speak of “ ulcer¬
ative dermatitis ” or 44 ulcerative stomatitis ” otherwise than as manifestations
of a whole group of different causes. I take it for granted that it is neither
the intention nor the wish of this meeting to enter into a discussion of all
possible causes of ulceration of the large bowel.

We may put on one side therefore such conditions as malignant disease,
tuberculosis, syphilis, actinomycosis, and other mycotic infections: intestinal

Section of Surgery : Sub-section of Proctology 101

schistosomiasis, and, perhaps, amoebic dysentery—although one is tempted to
include this in the discussion. Such specific fevers as cholera and typhoid
need not detain us; though we should remember that, in the latter, ulceration
need not be limited to the ileum, but may attack the solitary lymphoid
follicles of the large bowel, especially the caecum.

An acute catarrhal enteritis may, of course, occur as part of, or as a
complication of, many acute infective conditions of known, or unknown,
causation, for example, some of the acute infectious fevers, such as scarlet
fever, diphtheria, or measles; and may go on to follicular ulceration,
particularly in the caecum, as well as in the small intestine, especially the
lower part of the ileum; and such ulceration may spread and lead to the
formation of more extensive ulcers. Similarly, follicular and more extensive
forms of ulceration may supervene in various chronic catarrhal conditions of
the intestine, and may be found especially in cases of chronic nephritis, waxy
disease, &c.

We may, however, usefully concentrate our attention upon those cases of
ulcerative colitis in which that lesion is the outstanding clinical feature of the
case, and in which the ulcers tend to be of considerable size. Bacillary
dysentery, the paratyphoid and allied infections, and cases in which we may
suspect the causal importance of such organisms as Bacillus pyocyaneus ,
pneumococci, streptococci, and enterococci, &c., either singly, or in com¬
bination, may, I think, usefully occupy our attention.

In any one of these infections, one may find all degrees of implication of
the intestinal mucous membrane, from a mere slight surface catarrh, up to
severe and extensive ulceration; and it appears to be a point of extreme
importance that we should remember that, even if such ulceration be due
originally and primarily to one specific type of organism, it speedily becomes
a “ mixed infection,” in which a whole series of bacteria all take part in
attacking the bowel-wall. So much is this the case that, except in a few
instances, one cannot definitely be certain of the presence of a specific
organism, and we have to treat the condition as one of mixed infection. Even
when one obtains one of the paratyphoid, Gartner, or dysentery bacilli, from
the faeces, such secondary mixed infection has occurred if ulceration has taken
place; and one has to boar this fact in mind if we determine to treat the
condition with vaccines or sera. Thus, in some forms of bacillary dysentery,
in which a vaccine made from the dysentery bacilli may not be suitable
because of its great toxicity, the specific serum may with advantage be used
along with a mixed vaccine made from the organisms of secondary infection.

Personally I have not had much experience with the treatment of typhoid
fever itself with vaccines; but, in a considerable number of cases of para¬
typhoid infection I have obtained better results, if the bowel has been
ulcerated, by using a vaccine containing both the autogenous paratyphoid
bacilli and a suitable selection of the other organisms in the faeces likely to
take an important part in secondary infection, including the patient’s own
Bacillus coli , streptococci, &c.

When vaccines first came into use the practice was laboriously to isolate
the various organisms, e.g., from the nose, or throat, or sputum, &c., and to
prepare the vaccine from some single organism, say a pneumococcus or strepto¬
coccus, or the like, which one took to be the primary, or the chief, infective
agent. But now, I have practically discarded this method, and, by making
use of a widely varying series of culture-media, we can, by selecting from them,
obtain a bacterial emulsion approximating, as closely as possible, to the

102 Carnegie Diokson: Discussion on Ulcerative Colitis

organisms found in direct films of the original exudate; and I find that such
a mixed vaccine, is incomparably more efficacious than the single-organism
vaccine.

In cases of colitis it is sometimes a matter of very great difficulty to
determine which of the organisms present are of greatest importance; and I
would plead for the use of an extended series of culture-media in such cases.
A bacteriological report founded upon a single agar plate from the faeces is of
little use, and may, indeed, be quite absurd, for example, where practically
nothing but Bacillus coli grows, or Bacillus coli with a smaller or greater
number of colonies of “ enterococci,** staphylococci, and the like.

My own practice is to put on, as a routine, a series of agar, blood-agar,
broth, blood-broth, anaerobic meat-broth, litmus-milk, MacConkey lactose agar,
and, sometimes, other media; and the extraordinary differences in the variety
and number of the various organisms grown from the faeces in these different
media are very striking, and from them one may “ average up ** the result of
the whole investigation.

Perhaps the greatest handicap from which the bacteriologist suffers is that
he has to report some more or less definite finding within a more or less
reasonable time; whereas, for the full scientific investigation of the case, he
would require three weeks, or a month, or more, to isolate his organisms in
pure culture, and give them long enough in the differential culture-media to be
certain of their biological reactions. This, of course, is impossible in the great
majority of cases, and he has to be content with such approximate results as
he can rapidly obtain in one, two, or three days, or so. Fortunately, some of
the more important pathogenic organisms can be comparatively rapidly isolated,
and identified by specific serum-tests ,* but there are many organisms in the
fasces probably of great importance, which are either slow-growing, or their
growth is limited or inhibited by the presence of other organisms. Every
bacteriologist is familiar with the fact that his cultures from the faeces, if left
for a week, or several weeks, or, for that matter, several months, show an
extraordinarily different picture from that obtained in the first day or two.
A dozen or more varieties of organisms may have come to light in what seemed
at first to be, perhaps, a pure culture of Bacillus coli , or the like.

One organism of, I believe, considerable importance in connexion with
colitis, ulcerative and otherwise, is Bacillus pyocyaneus ; and the recognition
of its presence may be difficult in early cultures because it requires a copious,
supply of oxygen for the production of its characteristic pigment; and tho
production of this pigment may be prevented by the presence of other organisms
which use up oxygen, or in some other way. It may, in fact, sometimes bo
detected only after repeated plating-out. In a series of colitis cases, including
those with severe ulceration and haemorrhage, I have, in seven cases, found
Bacillus pyocyaneus present, and have sometimes also obtained it from tho
blood and urine in these cases, which may clinically resemble typhoid or
paratyphoid fever.

It would take too long to enumerate the many non-lactose-fermenting
Gram-negative bacilli, classified and unclassified, which one finds in these
cases of ulcerative colitis ; and, if one were to include the lactose-fermenters
as well, the task would be endless. Castellani, for example, gives a list of
about 100 of these; and Mr. Lockhart-Mummery has referred to the clinical
aspects of a case of very severe haemorrhagic ulcerative colitis, in which I
found a paratyphoid-like organism corresponding with Bacillus carolinus of
Castellani in that list, this case being treated with an autogenous vaccine and

Section of Surgery: Sub-section of Proctology 103

the administration of Bacillus bulgaricus , in addition to surgical and other
measures.

It would take up too much time to deal with the question of vaccine
treatment of individual cases and individual infections; and I must content
myself with the above remarks as to the greater efficacy of mixed vaccines
over single-organism vaccines, this being specially so in the case of the colon ;
although it may not apply so much to ulceration higher in the bowel, for
example, in the duodenum; for, in duodenal ulcers, one sometimes obtains
excellent results with a vaccine made from streptococci alone. In all such
cases, local and general medical and surgical treatment, appropriate to the case
and to the nature of the lesion, should always be employed along with the
vaccine administration, which should be regarded as assisting, but not replac¬
ing, such ordinary measures. The neglect of this common-sense rule often
brings vaccine administration into undeserved bad repute.

I have found agglutination and other immunity*tests with the patients
serum of comparatively little immediate practical value, and often, indeed,
probably fallacious, in determining the specificity, or otherwise, of organisms
isolated from the faeces. Every bacteriologist knows that even typhoid and
paratyphoid bacilli, when newly isolated from the body, may not be specifically
agglutinated by the patient’s own serum, and may only develop the capacity
of being so agglutinated after repeated culture and subculture. High-potency
experimental sera obtained by the inoculation of animals, are, however, a
valuable, through laborious, means of identification of certain organisms, e.g.,
the strepto- and pneumo-cocci; but they are, of course, part of the routine
method for members of the typhoid-paratyphoid-dysentery group.

I have confined my remarks, in helping to open this discussion, more or
less to general principles, and later speakers will doubtless deal with many of
these points in greater detail; but I may, perhaps, be permitted, for one
moment, to refer to the question of the origins of such infections, and to some
of the pathological and bacteriological examinations which may help in
diagnosis.

We have already noted that a colitis may form merely part of a general
acute, or other form of infective disease. In many cases, the infective agent
may be ingested with food or drink; but, in the absence of any evidence
pointing to such sources, the physician or surgeon should always consider the
possibility of other sources of infection in the body itself: more particularly
the presence of septic teeth, tonsils, nasal sinuses, &c., and whether the
appendix is involved. Especially in obstinate and long continued, or in cases
of constantly recurring, colitis, the appendix often acts as a residual focus of
infection; and, in such cases, a cure is often not effected until it is removed.

Lastly, one may obtain important collateral evidence as to the nature of
the infective organisms from cultural examination of the blood, and of very
carefully taken catheter-specimens of urine, as the kidneys are specially con¬
cerned with the elimination of organisms which have entered the circulating
blood. One is, of course, familiar with the presence of Bacillus coli t typhoid
and paratyphoid bacilli, &c., in the urine ; but one may also find various other
organisms, such as streptococci, Bacillus pyocyaneus , and various unclassified
bacteria, probably of faecal origin, which may have entered the circulation
from an inflamed and ulcerated bowel. One need scarcely add that a general
blood-examination may often be helpful. In my own series of blood counts in
such cases, I have usually found a leucopenia, the diminution affecting
especially the polymorphs, and thus producing a relative lymphocytic increase:

104 Carnegie Dickson—Dudgeon: Discussion on Ulcerative Colitis

And a secondary anaemia, especially a haemoglobanaemia. I agree with Sir
Thomas Horder as to the occurrence of leucopenia in many chronic strepto¬
coccal, just as much as in coli-typhoid-paratyphoid, infections, and I have also
observed that injections of normal horse-serum in such cases of leucopenia
often bring about a rise to normal of the leucocytes, or even a distinct
leucocytosis. One interesting point which I have often noted in cases of
enteritis, with or without ulceration, is the diminution or absence of eosinophils
from the peripheral circulation, these cells often accumulating in enormous
numbers in and around the intestinal lesions. It is scarcely necessary, of
course, to remind you that these cells are often, though by no means con¬
stantly, increased in the peripheral circulation in intestinal infections with
worms.

Professor Leonard S. Dudgeon.

My remarks concern entirely the sporadic form of a disease known chiefly
in this country as ulcerative colitis.

Sir William Hale-White has argued by every means at his disposal that
this disease is distinct from true dysentery, whilst others have urged that
ulcerative colitis is simply bacillary or amoebic dysentery as met with among a
population who have not visited countries where dysentery occurs in endemic
or epidemic form. Personally I do not regard such evidence as of the slightest
importance at the present day. The late Dr. F. M. Sandwith, who was a
recognized authority on dysentery, severely criticized in his Lettsomian
lectures in 1914, the view that ulcerative colitis is distinct from dysentery.
It may be advantageous to quote two paragraphs from these lectures : “ No
one acquainted with both these diseases can have failed to appreciate the
resemblances as regards symptoms and post-mortem appearances which one
bears to the other ” ; and again, “ We are confronted by an illogical outcome,
for a case diagnosed as ulcerative colitis in a London hospital ward might be
relabelled if it were discovered later that the patient had lived in the tropics
and that his faeces contained amoebae or bacilli.” No advantage will be gained
by further discussion of the arguments brought forward by various writers on
this subject. My own interest in this disease was first made possible about
1908 owing to my association with Dr. H. P. Hawkins at St. Thomas’s
Hospital. Hawkins had come to the conclusion from his study of the disease
that more elaborate bacteriological methods would probably lead to the
solution of the problem. He made use of the rectal speculum so that
scrapings could be made from any visible ulcers, which would afford greater
opportunities to the investigator than mere examination of the fasces. By
this method I was able to isolate a strain of the Flexner bacillus from a case
of ulcerative colitis when repeated examination of the fasces had been
unsuccessful. Dr. Hawkins believed that by this method of direct examination
of the intestinal ulcers the causative organism of ulcerative colitis would be
identified. This important line of investigation, which was commenced by
him about 1907, has been greatly extended by Manson-Bahr and Gregg, who
have employed the use of the sigmoidoscope for the examination of intestinal
ulcers. It is fully recognized by those of us who have had personal experience
of bacillary dysentery in all its forms that the isolation of true dysentery
bacilli is infinitely more difficult in the presence of faecal material, and still
more so in pure diarrhceic stools without mucus, while the chances of
successful findings is still further diminished if specimens containing faecal

Section of Surgery : Subsection of Proctology 105

material are not examined at the earliest possible moment. In my experience
typical dysenteric stools are exceptional in cases of ulcerative colitis, while
abundance of muous such as occurs in true dysentery is uncommon. The
motions in ulcerative colitis are usually diarrhceic in character, while blood
may occur in large or small amount. These facts have helped to influence
previous observers to regard ulcerative colitis as distinct from true dysentery*
in spite of the fact that any variety of stool is met with in Flexner and to a
much less extent in Shiga infections. Since the war I have seen six sporadic
cases of so-called ulcerative colitis in this country and have isolated a Flexner
bacillus from one of these, while from four of the others almost pure cultures
of haemolytic colon bacilli were obtained, and from the sixth case abundance
of haemolytic streptococci and the Staphylococcus aureus , even on repeated
examinations. The patient in Flexner case had not been abroad, but, as already
stated, I do not regard this fact as of any practical importance. Serological
examinations in each case were made, but with negative results with my Shiga
and Flexner antigens. I have not met with any case diagnosed as ulcerative
colitis from which the free or encysted form of Entamoeba histolytica was
obtained, or in which the intestinal ulceration resembled the amoebic form of
dysentery, or in which a solitary abscess of the liver existed. In every case
of ulcerative colitis, in my experience, the intestinal lesions have resembled
those of bacillary dysentery. I must admit, however, that I saw cases in the
East during the war in which there had been dysenteric symptoms during
life; the intestines showed intestinal ulceration such as occurs in bacillary
dysentery, but the Bacillus paratyphosus B or C were isolated from the faeces
during life. The whole argument appears to me to rest on the bacteriological
or protozoological findings. If, in a case diagnosed as ulcerative colitis*
evidence of a true dysenteric infection, in spite of full investigation, cannot be
obtained, the clinical diagnosis must remain. The term “ ulcerative colitis **
has the distinct advantage that it merely signifies the morbid process met with
in the large intestine, associated with certain clinical phenomena.

In conclusion, I am opposed to the view that ulcerative colitis and true
dysentery are of necessity caused by the same specific organisms, because I
believe that such a condition as ulcerative colitis may be due to other bacteria.
I have, however, referred to two cases of typical ulcerative colitis which
ultimately proved to be Flexner infections. For this reason I consider it
essential in every case diagnosed as ulcerative colitis to employ the following
lines of investigation, as it is only by such means that the effective nature of
the disease can be ultimately settled :—

(1) Examination of the bowel by means of the sigmoidoscope.

(2) If ulceration is present material should be obtained from the floor of
the ulcer or ulcers and should be submitted to a detailed bacteriological and
protozoological examination.

(3) Repeated examination of the faeces.

(4) Examination of the blood, more especially in relation to the presence
of immune substances in the serum.

It is to be hoped that as a result of this discussion a combined effort will
be made for the study of such cases as occur in the future.

106

Hurst: Discussion on Ulcerative Colitis

Dr. A. F. Hurst.

My remarks will deal with the treatment of ulcerative colitis and bacillary
dysentery by anti-dysenteric serum.

The first description of the sporadic ulcerative colitis occurring in England
was published in 1875 by Sir Samuel Wilks, who pointed out that it was
anatomically indistinguishable from dysentery. Saundby, in 1906, and
Hawkins, in 1909, came to the same conclusion as a result of clinical
and pathological investigations, but without using the sigmoidoscope. In a
report on an epidemic of " idiopathic ulcerative colitis,” which resulted in
118 deaths in the Lancaster County Asylum in 1898, Gemmel expressed his
belief that this condition, which had always been well known in asylums,
was really dysentery. Vedder and Duval, working under Flexner in 1902,
proved that epidemics of dysentery occurring in institutions in America were
caused by the Bacillus dysenteric, and two years later Eyre showed that
asylum dysentery in England was also caused by this organism. All attempts,
however, to isolate the bacillus from sporadic cases have failed, though in
a small number the blood has strongly agglutinated Flexner's bacillus.
A diagnosis of ulcerative colitis can only be made with the sigmoidoscope.
It is first necessary to exclude a growth beyond the reach of the finger. It is
then neceesary to decide what form of colitis is present, to ascertain the
severity of the condition, and to exclude the possibility of amoebic dysentery,
even if the examination of the stools has proved negative, for I have seen a few
cases in which this infection developed in patients who had not been out
of England. An anaesthetic is very rarely required, as the passage of the
instrument does not cause pain unless the anal canal is inflamed ; in such cases
a cocaine sempule should be introduced a quarter of an hour before. If the
sigmoidoscope is carefully introduced under visual guidance without inflation
and only as far as it goes without difficulty, there is no danger, the few cases
in which perforation has occurred having all apparently been due to its blind
passage. In ulcerative colitis the mucous membrane is bright red and thick,
the swelling being particularly obvious in the normally thin Houston’s folds.
It bleeds very readily when touched, and its surface is covered with blood¬
stained, purulent mucus. Superficial ulcers are invariably present, but in early
cases they may be so small that they are difficult to recognize. More frequently
they are of larger size and are sometimes so extensive that only small islets of
mucous membrane are left, which may feel like small flat polypi on rectal
examination, the floor of the ulcers being mistaken for the surface of the
mucous membrane. The ulcers are always superficial, with irregular edges,
and the thick mucous membrane is not undermined. The floor of the ulcers
appears greyish-yellow when the blood and mucus are wiped from their surface.
In some cases the sigmoidoscope shows that the rectum or the rectum and
lower part of the pelvic colon are alone inflamed, as normal mucous membrane
is found higher up, but it is doubtful whether the proximal part of the colon
is ever involved without the pelvic colon and rectum.

I have often watched with the sigmoidoscope the process of healing.
When healing occurs new mucous membrane forms ; owing to the superficial
nature of the ulcers very little scarring occurs and strictures never develop.
When the sigmoidoscope is passed after complete recovery from ulcerative
colitis or bacillary dysentery, nothing more is seen than some very slightly
puckered areas in the mucous membrane, which may be a little paler and

Section of Surgery : Sub-section of Proctology 107

smoother than normal. During the war I had several opportunities of
examining the colon with the sigmoidoscope in cases of acute dysentery, and
since then I have examined a considerable number of chronic cases in the
same way. The differences between the appearance of the mucous membrane
in amoebic and bacillary dysentery are so marked that a diagnosis can be made
with the sigmoidoscope of one from the other with a considerable degree of
certainty. I was much struck from the first, however, with the fact that the
appearance of the mucous membrane in bacillary dysentery is indistinguishable
in life, as Wilks had observed post-mortem, from that of the sporadic ulcerative
colitis which occurs in England. On the other hand, in amoebic dysentery
small, round, red elevations are seen on the otherwise normal-looking mucous
membrane, corresponding to the collection of broken-down material in the
submucous tissue caused by the invasion of the Entamoeba histolytica . In
the centre of each elevation there is a depressed yellowish ulcer, caused by the
rupture of the submucous abscess through the mucous membrane.

In view of the very favourable effects I had obtained in chronic as well as
acute bacillary dysentery by the intravenous injection of large doses of the
polyvalent anti-dysenteric serum of the Lister Institute, I decided to try the
effect of the same treatment in ordinary ulcerative colitis. The results have
been remarkably favourable. They are not, I believe, due simply to the use
of horse serum, but are definitely specific. In a severe case under my care
I tried the effect of large doses of ordinary horse serum; no improvement
resulted, but the administration of anti-dysenteric serum after a week’s interval
had the usual rapidly favourable result. I generally begin with an injection of
40 c.c. intravenously ; this is followed on consecutive days by injections
of 60, 80 and 100 c.c. The four injections are often sufficient, but it may be
necessary to repeat the maximum dose two or three times. A considerable
reaction often occurs; the patient’s temperature rises and a profuse erythe¬
matous rash appears. The joints may become swollen and painful. But these
symptoms generally only last a few hours, and never longer than a few days.
I think they are less likely to occur if 15 gr. of calcium lactate are given
three times a day the day before and during the days of treatment. No
anaphylactic symptoms have been observed, even in patients. who had
previously had serum, but care was always taken to desensitize the latter by
very small preliminary injections, and the same precautions would be necessary
in any patient who was subject to asthma.

I have employed this treatment in about ten cases. Very rapid improve¬
ment has always taken place, though in one case in which appendicostomy had
been performed some months earlier, it was incomplete. A secondary strepto¬
coccal infection had apparently become grafted upon the original dysenteric
infection, as complete recovery only took place after the removal of the teeth,
which was followed by a temporary severe local reaction. An attempt to treat
this patient with a vaccine prepared from streptococci isolated from the stools
had to be given up owing to the violent reaction which followed the injection
of only a quarter of a million bacteria. My colleagues, Dr. John Fawcett and
Dr. J. A. Kyle, 1 obtained an equally satisfactory result in one case under their
care. The treatment failed in two others, but in both of these they recognized
the ulcerative colitis as being of a hypertrophic character quite different from
the ordinary type, so that in all probability it was caused by a different

1 Guy's Hosp. Gaz. t 1928, xxxvii, p. 136.

108

Hurst: Discussion on Ulcerative Colitis

infection. One of these cases died shortly afterwards from perforation, which
rarely, if ever, occurs in the usual form of ulcerative colitis, and in the
other an appendicostomy, which was subsequently performed, led to no further
improvement. Dr. B. E. Jerwood 1 had also reported a case in which the
patient was “ incontinent, very weak, wasted, and quite determined to die,”
and in which rapid recovery followed treatment with antidysenteric serum.
In most cases the improvement was as rapid as that of amoebic dysentery with
emetin and epidemic bacillary dysentery with intravenous anti-dysenteric serum.
In my first case the patient was so ill when I first saw him that I advised an
immediate appendicostomy. In spite of this the patient went steadily down
hill, and a fortnight later, when the first injection was given, his condition
appeared to be almost hopeless. But in three days the blood had disappeared
from the stools, in five the sigmoidoscope showed that the mucous membrane
was entirely free from ulcers, though still a little red, and in ten days
the stools were normal and the mucous membrane was perfectly healthy,
though the ulceration before the first injection was most extensive.
I discussed the details of treatment by rest, diet, albargin injections, and
charcoal, in the Guy's Hospital Reports for January, 1921, when I first
described the results obtained with anti-dysenteric serum. They were of great
importance before the introduction of the serum treatment, but recovery rarely
took place in less than six months, and a year was often required. Until three
years ago I was therefore inclined to advise appendicostomy as an additional
measure in all cases of any severity. But since I have been using large
intravenous doses of serum I have not found it necessary to advise appendi¬
costomy in a single case, and I have only occasionally had recourse to albargin
injections. I realize, however, that there must be cases, such as the two
under the care of Dr. Fawcett and Dr. Ryle, already mentioned, in which the
pathology is different and in which serum will be useless. In these the
other methods of medical treatment, and appendicostomy, will be required,
but the possibility of amoebic dysentery, even in patients who have never been
abroad, and even if the pathologist has failed to discover amoebae or their cysts,
should always be remembered, as such cases recover very rapidly with emetin
injections..

No case can be regarded as cured until the sigmoidoscope shows that
the mucous membrane is perfectly healthy. It is then necessary to keep
the stools soft by the use of paraffin or saline aperients for several weeks until
the newly formed mucous membrane has overcome its original vulnerability to
mechanical irritation.

I conclude with a plea for the more extensive use of the sigmoidoscope.
It should no longer be regarded as an instrument for the proctologist or
surgeon alone ; it should be used by every physician, and to treat a case as
colitis without first visually examining the rectum and pelvic colon should be
regarded as equally as absurd as the treatment of a case of tonsillitis without
first looking at the tonsils.

1 Guy's Hosp . licp ., 1921, xxxv. p. 292.

Section of Surgery : Subsection of Proctology 109

Sir Charles Gordon-Watson.

I regret that I was not present to hear the opening of the discussion by
Sir Humphry Rolleston and Sir Thomas Horder. I was much interested in
hearing Dr. Hurst’s account of his success with anti-dysenteric serum. In
view of these results we certainly ought to give anti-dysenteric serum a more
extended trial in the acute cases of ulcerative colitis which clinically resemble
acute dysentery. In the chronic cases there is no doubt that results have
enormously improved in recent years with treatment by appendicostomy and
daily irrigation. I believe that the most generally useful fluid for irrigation
is a weak solution of flavine, which is non-irritating and non-toxic and is very
effective in neutralizing offensive stools. If appendicostomy is carried out
early recovery is usually rapid; advanced cases may end fatally in spite of
appendicostomy. The type of case most usually met with occurs in middle-
aged women, and starts as a chronic infection, but tends to become acute, if
neglected, differing in this respect from epidemic dysentery. It is important
that these cases should be kept under observation and under treatment after
the primary attack has subsided. The appendicostomy opening should not be
allowed to close, as recurrences are the rule rather than the exception, and attacks
may recur after several years of immunity. The cases which give the most
anxiety are those which are subject to severe haemorrhages. I have had a case
under my care with repeated attacks extending over the past twelve years ; on
two occasions this patient has been almost in extremis from severe haemorrhage
from the colon. Hot hazeline irrigation is valuable in haemorrhagic cases and
blood transfusion, when possible, is certainly indicated. There can be no doubt
that, in some instances, the affection of the colon is secondary and cannot be
cured until the primary focus has been dealt with. Two illustrative cases have
come under my notice: in one early case an inflamed appendix was removed
instead of being utilized for appendicostomy, and the patient made a good
recovery from the colitis without the caecum being opened for irrigation
purposes. In the other, treatment for an infected antrum resulted in, or at any
rate played an important part in the cure. I have not been much impressed
with vaccine treatment, but recently in a case under my care all efforts to
check the disease and to control the haemorrhage were unsuccessful until
a vaccine was employed. Within a week after the use of a vaccine the
temperature, which had been irregular for many weeks, became stationary, and
the patient made a rapid recovery. There was a recurrence, but this was
nipped in the bud by the use of vaccine.

Mr. Douglas Drew.

I am very disappointed with the operation of appendicostomy as a means
of treating of severe cases of ulcerative colitis; I have practised it in a
number of cases and have used irrigation and a large variety of drugs with
almost uniformly bad results. One patient, after many weeks of treatment,
left the hospital in what appeared to be a hopeless state but eventually she
recovered at home and returned some four years later in good health, having
in the interval had two children. The recovery could not be attributed to the
appendicostomy as it had closed long before improvement began to take place.
In another case the patient improved for some months after caBCOstomy and
then suffered a serious relapse and became so ill that it was decided, if possible,

110

Drew: Discussion on Ulcerative Colitis

to perform colectomy; on the abdomen being opened the colon and sigmoid
were found to be so much thickened and inflamed that an anastomosis was
impossible; the caecostomy was therefore detached and converted into a right¬
sided colostomy in the middle line. More than a year has elapsed since this
was done and the patient has greatly improved in health but still from time to
time has a slight temperature and discharge of pus from the bowel.

In these severe cases it is most important to put the bowel at rest by
diverting the faecal stream by means of a right-sided colostomy and I attribute
the failure of appendicostomy to the passage of the faeces over the ulcerated
surface.

Section of Suraen>.

President—Mr. James Berry, F.R.C.S.

The Treatment of Fractures of the Patella.

By R. H. Anglin Whitelocke, M.D., F.R.C.S.

FRACTURES of the patella are not uncommon and unless carefully treated
are liable to leave a permanent insecurity in the limb, a liability to refracture,
and to fracture of the other patella (fig. 1).

Various methods of subcutaneous treatment have from time to time been
introduced, practised, and then abandoned as insufficient. Without an open
operation true osseous union is almost unattainable and probably there are few

Fig. I.—Case of refracture some years (ten) after fibrous union without open operation.

surgeons, to-day who are not agreed on this point. Fibrous union, which is all
that can bo attained without an open operation, is relegated to those cases in
which for any reason such as age, organic disease or unsuitable surroundings,
the open operation is contra-indicated.

Fractures of the bone result from two very different forms of violence,
viz., (1) violent strain upon the bone by the extensor muscles of the thigh as
in a sudden attempt to avoid falling backwards, and (2) direct violence such
as a blow, kick, or fall upon the knee, and sometimes from a combination of
these factors ; traction and impact. They may be simple or compound, of tw r o
or many fragments. The tip, base, or edges of the patella may be avulsed in

O—S 1 [June 6, 1923.

112 Whitelocke: Treatment of Fractures of the Patella

strain-fractures, and in direct fractures split into as many as eight or nino
pieces. The line of fracture may extend in any direction, and the fragments
be of very unequal size.

In every fracture of the patella there is bleeding into the synovial cavity
of the joint and into the soft tissues around it—a point of much surgical
importance.

Sir William Macewen, 1 * 3 as long ago as 1887, drew attention to the fact that*
owing to the elasticity of the soft structures exceeding the cohesion of th&
bone in strain-fractures, the soft tissues do not yield at the same time as
the bone. As a result of this in almost every indirect or strain-fracture
a fibro-periosteal curtain curls inwards so as to envelop in part or completely
one or both fragments. Lucas-Championni&re* and Baerlocher, 8 writing in
1903, both laid stress on the surgical value of this observation. In only four
of my cases have I found it absent, and two of these were compound fractures.

The bony fragments are as a rule not widely separated except in long
standing cases, where the separation has been known to exceed 4£ in.; in one
such case of refracture the separation amounted to nearly 4i in. Refracture
usually occurs within a few months after the primary injury, and results from
atrophy of the distal fragment, adhesion of a fragment to the femur, or from
forcible flexion of the knee from a fall or too vigorous manipulations during
treatment.

If we call to mind the various factors concerned in keeping the fragments
apart and preventing bony union, such as muscular spasm, tearing of the peri-
and pre-patellar tissues and capsular ligament, the effect of haemorrhage and
effusion into and around the joint, the curling in and envelopment of the
fragments by the fibro-periosteal curtains already referred to, as well as
the frequent tendency to rotation or tilting of the distal fragment from the pull
of the patellar ligament, it is surprising that any other form of treatment
should be considered. And especially does this argument apply in cases of
long standing or refracture. In these, resection of inter-fragmentary soft
tissues and refreshing of bony fragments even with saw or chisel, are usually
an absolute necessity.

If we agree that only by open operation can bony union be secured, it
necessitates our making use of some method which, whilst overcoming most
of the difficulties likely to be met with, will also be of the greatest service,
and be universally adaptable.

Three methods in recent times have been practised and often with excellent
results, namely, osseous union, cerclage or circumferential looping, and a
meticulous suturing of all the soft tissues that have been tom. Not one of
these, however, seems sufficient by itself. Even the advocates of osseous
suture are obliged to repair capsular tears in addition.

For over twenty years I have abandoned osseous suture entirely and
substituted for it a combination of antero-posterior looping, with or without
cerclage , with an accurate sewing of all tissues that are torn; every suture
being of an absorbable material.

With a perfectly aseptic surgical technique there should be little or no fear
of suppuration, septicaemia, or ankylosis.

Stimson, 4 in 1907, had operated for fractured patella over 200 times with

1 Ann. Snrg ., 1887, Pliilad., v, p. 77.

* Lucas-Championniere, Archiv. Intermit, dc Chimrg 1908, i, p. 27.

3 Baerlocher, H., Cor.-Bl. f. Schueiz. Aerzte , 1903, xxxiii, p. 106.

4 Stimson, L. A., “ Practical Treatise on Fractures and Dislocations,” Philad., 1907

Section of Surgery

only a single slight mishap. In nearly eighty consecutive operations for cases
of indirect fracture I have had but one case of suppuration. This happened
in the last of my series, a case still in hospital. The patient, a man aged 28,
suffered during the war and since from shell-shock, and periodically from
psoriasis. This case I now realize was one quite unfitted for open operation
and it is recorded here to accentuate the importance of careful and full
investigation before operation. There was much bleeding into the joint before
and after operation and on the seventh day a catgut stitch came away with
some suppuration. The knee is likely to be stiffened though the fragments are
in fair position. Benjamin Tenny 1 notes that in 1897 only 16 per cent, of
cases were sutured in some fashion, whilst in 1906 the percentage was 60.
Apparently wire was used in all cases operated on previous to 1899, and
in 1906 there were more than three cases sutured to one wired.

Professor Heineck, of Chicago, wrote many years ago: “ In recent fractures
of the patella I have abandoned osseous suturing. I have not seen a case of
old fracture of the bone in which I felt that a good result could not be obtained
without employment of osseous suturing.” This has also been my experience-

For over twenty years I have practised and taught that osseous suturing was
quite unnecessary for long-standing as well as recent fractures, whether
indirect or direct. 3 I believed then, as I do to-day, that the disadvantages of
osseous suturing are serious and considerable.

The following are the objections to osseous suturing :—

(1) It is unnecessary. It adds injury to injury and equally good if not
better results may be obtained by less difficult and less laborious methods.

(2) It requires special instruments and considerable skill in handling them,
whilst they are liable to break even in skilful hands and remain embedded in
the bone or become lost in the joint.

(3) It is a method neither suitable nor applicable in a considerable number
of cases. It cannot be usefully employed when there is great inequality in the
size of the fragments. One or other fragment may be so small that there
cannot be sufficient hold for the wire suture or metal plate (fig. 2).

i Tenny, Benj-i Ann. Surg ., 1908, xlviii, p. 719.

1 Whitelocke, Brit. Med. Journ. } 1910, ii, p. 292.

114 Whitelocke: Treatment of Fractures of the Patella

Unusually brittle bones are liable to splinter; drilling or boring them
causes additional injury.

In cases of secondary operation the fragments, especially the distal fragments,
may be and often are so atrophic as to be incapable of holding the sutures,
which cut out as soon as strain is put upon them. When wire sutures break
and screws or plates become loose they may fall within the joint and require
removal.

Open circumferential looping or cerclage was introduced by Berger, 1 of
Paris, as a supplementary measure to osseous suture in cases in which the
fragments were too small for successful suture, in cases of much comminution,
and when the bones were unduly friable. It is the only method of suture
used by some, but it cannot be relied upon as entirely sufficient, though safe
and serviceable in many cases.

Simple suture of the capsule and lateral patellar ligaments and all the soft
tissues that are torn has met with marked success, and in some cases of recent
fracture may be all that is required. In this particular class of case the
fragments fall readily together, and when the limb is kept in extension there is
but little strain upon them. On the other hand in long-standing cases, and
where the strain is great it is not always sufficient, and must be supplemented
by antero-posterior looping. The ultimate strength of the tendon or bone
depends upon its capacity to reproduce its own tissues, and any suture
material remaining at the end of four or six weeks is but a useless foreign
body, troublesome if not dangerous. Accurate stitching of the soft tissues
would seem to be of even greater service than complete restoration of the
patella itself, and it is always safer to remove any small fragment of bone or
articular cartilage which cannot be kept accurately in place by stitching.
Such a loose portion may do harm later by furnishing a roughened posterior
surface to the patella or even become detached and fall into the joint, grow,
and increase considerably in size as a loose wandering body. 2

I have found the following operation suitable for all cases of patellar fracture,
whether simple or compound, due to strain or impact, recent or of long-standing.
It is entirely simple, and is adaptable, as far as I have experienced, to every
possible condition likely to be met with. The requirements have all been met,
bony union has followed and good functional results have been attained. I know
of no case of refracture nor of stiff joint resulting from an operation for recent
fracture except the one mentioned. In two cases of compound comminuted
fracture there was for a time some widening of the patella, enough to produce
a misfit, and some limitation of complete flexion which was overcome eventu¬
ally. In one case the movements were free and good in six months, in the
other in ten months. In compound fractures the operation should be per¬
formed as soon as possible. Delay is injudicious owing to the risk of sepsis
and all that this means. Every effort should be made to counteract the possible
infection by cleansing not only the skin but the articulation and lacerated
tissues. In recent subcutaneous fractures there is no immediate call, and there
are many advantages to be gained by waiting a few days. Opportunity is
afforded of studying the precise condition, and of procuring a proper and
suitable operative field. The patient is kept in bed with extended knee and
elastic compression over it to limit intra-articular bleeding.

The limb is shaved and the knee washed carefully each day with alcohol

* Berger, Bull, et Mem . dc la Soc, de Chir, } Paris, 1692, xviii, p. *523.

* Whitelocke, Brit. Journ. Surg. } 1914, i, 650.

Section of Surgery

115

and enveloped in an aseptic dry dressing until the time of operation. I do not
now use a tourniquet or elastic bandage for operations on the knee. I find
these inconvenient, unnecessary, and likely to promote undue oozing. A
general anaesthetic is the routine. The skin incision should be adapted to circum¬
stances, but must always be of sufficient size to allow of full exposure of the
whole operative field and proper cleansing of the joint, as well as adequate
suturing of all tears. Formerly I used the classical longitudinal incision, now
I use a curved one with the base of the flap on the inner side of the joint. The

FlO. 3.—Showing how the catgut sutures are passed with needle, after
beginning in middle line.

joint is not irrigated but swabbed gently with normal saline. At one time I
used kangaroo tendon, now almost invariably non-chromicized No. 3 or 4
catgut, both for encircling the fragments and suturing the soft tissues. I regard
it as positively unwise to leave any non-absorbable suture material permanently
either in the articulation or in the peri-articular tissues.

Metallic sutures, whatever may be said to the contrary, frequently break
across or become detached, and remain in the joint or tissues around. I have
myself seen and removed pieces of wire, portions of drills, and even screws and

116 Whitelocke : Treatment of Fractures of the Patella

plates from joints after attempts at osseous suture of the patella had been made
by skilled and competent operators. Metallic substances inserted into bones
that are subject to movement and strain will very frequently become loosened
in time, or cut out and set up subsequent irritation.

As sure as constant pressure will induce atrophy or thinning in any living
tissue, so will a metallic or other foreign substance, inserted and left in the
body, tend to become loose and set up irritation. The joint is always searched
for detached portions of bone or articular cartilage. These are removed if too
small or incapable of safe replacement.

Fig. 4 .—Sutures tied and periosteum stitched.

Every portion of fibro-periosteal tissue found between the fragments must
be carefully removed, if necessary with a curette. At this stage, in recent
cases, the fragments usually fall together readily, whilst in long-standing
injuries it will be necessary to remove the inter-fragmentary tissues and refresh
the bony fragments with saw or chisel. This having been done, the separated
portions are brought together and united by passing a long-handled needle
(fig. 3) threaded with No. 4 catgut through the centre of the patellar
ligament behind the distal fragment through the joint and from behind f or .

Section of Surgery

117

wards immediately above the proximal piece. Two or three similar threads
are passed on each side of this in the same way. These strands of gut
are tied tightly across the patella after the fragments have been placed
in accurate apposition, and the periosteum stitched (fig. 4). This is usually
a simple matter in recent; cases, whilst in those of long-standing it will
sometimes require much manipulation and even partial division and stretching
of the extensor muscle, or detachment of the patellar ligament at or near its
insertion. In comminuted fractures and where there is obliquity rather

Fio. 5.—Antero-posterior sutureR tied, supplemented by circumferential
looping {cerclage),

than the usual transverse splitting of the bone, in addition to the antero¬
posterior peri-articular sutures, I pass one or two catgut sutures by circum¬
ferential looping around the bone (fig. 5). After this, all the soft tissues that are
torn are stitched accurately, but not too closely, so as to leave sufficient space
here and there between them to allow of drainage of fluids from the synovial
eavity. The skin wound is closed with silkworm sutures and drainage is dis¬
pensed with. If drainage for any special reason be indicated, a strand of
twisted silkworm gut is used for forty-eight hours, not longer. Over the knee

118 Whitelocke: Treatment of Fractures of the Patella

a thick absorbent dressing is applied and bandaged firmly to exert constant
elastic pressure. In recent cases, and in those in which there is but little
tension or strain, the firmly applied elastic dressing, if carried well above and
below the joint, is all that is needed to keep it from being flexed unduly.
In some cases, especially in long-standing ones, a light moulded back splint
should be applied and retained until at least the wound is healed. In cases of
refracture, and of long-standing, when the fragments are brought together
with difficulty and there is strain, it is advisable to flex the thigh and

Fig. 6. —Comminution, antero-posterior looping and cerclage six weeks
after. Note size of patella.

Fig. 7. —After antero-posterior looping (six and a half months). Note (usual)
greater density of proximal fragment.

elevate the limb for a few days. I usually allow walking after twenty-eight
days and encourage voluntary movements in the foot and ankle from the first
day. When this voluntary routine is maintained regularly, passive movements
and early massage are seldom, if ever, required. Active voluntary movements of
joints are never overdone by the patient , whilst early passive movements , unless
carefully regulated , are seldom , if ever, without risk in every injured joint. The
after-care is of much importance, and well regulated movements should be con¬
tinued under supervision until the limb is restored to strength and the move¬
ments of the knee complete. Eight weeks is usually ample time for ordinary

Section of Surgery

119

purposes. Unless the patient in the end is able to run upstairs or climb a
ladder as well as before the accident, the result cannot be considered good. I
would even go further and say that unless an athlete can play at his games or
a workman balance himself on a roof the result is not ideal. I believe that
the number of cases of long-standing disability are becoming rarer, since
most surgeons now perform an open operation nearer the time of the
accident.

I regret being unable to give full or comprehensive statistics of my
cases, for I do not possess either the records or the pictures of any of the
cases upon which I operated during the war. It is my belief, however,
based upon a considerable experience, that the very simple methods just
described will prove satisfactory and helpful to any who may wish to try
them.

In conclusion, I may add that similar methods of suturing are used both
for ruptures of the patellar ligament with upward displacement of the bone
and for fractures of the olecranon.

Figs. 2, 6, 7 show results of union after antero-posterior looping and
cerclage .

The Closure o£ the Suprapubic Urinary Fistula following
Suprapubic Prostatectomy ; Observations on Sixty-eight
Cases.

By H. P. Winsbury White, F.R.C.S.Eng.

The sixty-eight cases are from a series of seventy-seven consecutive cases
operated upon at St. Peter’s Hospital, between April and November, 1921.
Of the nine cases not included, none survived convalescence. I have to thank
the staff of St. Peter’s Hospital for permission to publish these notes.

The purpose of this paper is to consider:—

(1) All factors which have a possible influence on the time of closure of the
suprapubic urinary fistula;

(2) The utility of the indwelling catheter.

The subject is dealt with under the following headings :—

(1) Brief outline of post-operative treatment.

(2) Division of cases into groups in relation to the employment of an
indwelling catheter.

(3) The use of the indwelling catheter.

(4) The operative procedures.

(5) The onset of micturition.

(6) The time of removal of the suprapubic drain.

(7) Secondary haemorrhage.

(8) Malignant cases.

(9) Summary.

(1) Brief Outline of Post-operative Treatment.

The parietal and bladder wounds were closed round a Freyer’s tube [l],
at the end of the operation ; and in some cases according to the tastes of the
individual surgeon, a small rubber drain was inserted into the prevesical
space.

[June 6, 1923.

120 White: Closure of the Suprapubic Urinary Fistula

At the end of three or four days Freyer’s tube 1 was replaced by a smaller
one, the urine, meanwhile, escaping into suprapubic cellulose dressings [2],
retained by a many-tailed bandage, and changed four-hourly. In a few cases
in which the prostatic cavity had been packed at the operation as a precaution
against haemorrhage, the gauze was removed on the third day. The bladder
and prostatic cavity were irrigated daily, both by the suprapubic route and by
Janet’s method [3], On the tenth day a large steel sound was passed per
urethram, the skin sutures were removed, and in the majority of cases the
suprapubic drain was finally dispensed with. The patient was allowed to sit
in a chair towards the end of the third week, unless prevented by some
complication supervening, or in anticipation of an indwelling catheter, and was
not discharged from hospital until the suprapubic fistula was closed.

(2) Division of the Cases into Groups in Relation to the
Employment of an Indwelling Catheter.

The following grouping as shown in Table I (p. 125) has been found con¬
venient :—

Group I.—All cases in which fistulae were finally closed by the twenty-eighth day
without an indwelling catheter.

Group II.—All cases showing signs of delay in closure of fistulae, subdivided as
follows : (a) Treated with an indwelling catheter; (b) indwelling catheter contra¬

indicated for time being.

The cases under ( b) terminated in one of two ways: (1) Spontaneous
closure in due course; (2) closure following delayed use of indwelling catheter.
The actual figures are given in Table I.

Of those cases in which the fistulae did not close in response to the in¬
dwelling catheter, it is interesting to note that two-thirds had not commenced
micturition up till the time at which the catheter was tied in. The importance
of the catheter in such cases will be referred to later. It will be noted that
the fistulae of the cases in which the indwelling catheter was used closed
sooner than in the others, thus demonstrating its value.

The following were the conditions which supervened and which prevented
' or delayed the use of an indwelling catheter : (1) Acute epididymitis; (2)
pyelonephritis ; (3) slough or phosphatic deposit on the wound surfaces.

By far the commonest of these was acute epididymitis accounting for about
54 per cent. The part played by acute epididymitis in determining delay
depended on whether the complication supervened early or late in the con¬
valescence. If early, there was not necessarily a contra-indication for the
catheter about the fourth week.

In a previous paper, entitled “ Epididymitis and Suprapubic Prostatectomy
—A Study of Fifty Cases ” [4], the writer showed that 64 per cent, acute
cases occurred during the first week of convalescence. In the few cases in
which an indwelling catheter was tried, in the presence of some degree of
pyelonephritis the result was always to increase rather than to diminish the
signs of infection. It was, therefore, found more satisfactory in such cases to
dispense with the catheter entirely. It is questionable whether in such cases
urethral instrumentation of any kind should not be avoided, and this practice
of avoidance was observed.

With regard to slough or phosphatic deposit on wound surface, in a few

1 Measurements of Freyer’s tube : l in. tubing, g in. lumen, 4 in. in length.

Section of Surgery

121

cases a coating of pbosphatic deposit on the wound surface occurred. It
appeared early, and commenced to peel off as a fine slough about the end of
the third week. An indwelling catheter could serve no useful purpose until
the granulations were free from slough. Moreover, these cases were rather
prone to acute epididymitis and pyelonephritis.

In other cases it was unusual for the portion of the parietal wound closed
by suture not to heal by first intention. The open portion generally showed
healthy granulations by about the seventh day. Two-stage prostatectomy
cases, however, were an exception to healing by first intention, as the wound
invariably broke down in the subcutaneous area.

(3) The Use of the Indwelling Catheter.

The ideal sought and encouraged was undelayed closure without the aid of
an indwelling catheter: but in many cases in which fistulas persisted without
any indication being given of their closing, closure was established at once
by a judicious use of the catheter; and again, in those cases of delay in
recommencing micturition, the indwelling catheter re-established the habit,
which was an essential before closure would occur.

The reason for avoiding the use of the indwelling catheter, if possible, is
that it is a foreign body in the urethra and granulating prostatic cavity, and
in the presence of already existing sepsis tends to produce more.

The urethritis set up appears to be in proportion to the length of time
the catheter is left in. No amount of care can prevent a purulent discharge
from the urethra which has borne a catheter for six days. The discharge is
serous till about the third day.

In prolonging unduly the use of an indwelling catheter in the hope of
providing an efficient dependent drainage, it should be borne in mind that
the value of the procedure is being minimized to some extent by the inevitable
sepsis which will result from the presence of the catheter in the urethra.
In this series of cases the practice was followed of not leaving the catheter
in for longer than three consecutive days. In none of the cases did such
usage give rise to any complication. On the other hand, it is not difficult to
produce acute epididymitis by leaving a catheter in position for a week. In
addition, its vesical end becomes coated with urinary salts [5]. In order to
get the maximum benefit in the minimum of time, it is essential that the
catheter be not resorted to, too soon [6]. When any doubt arose as to
whether a case was ready for an indwelling catheter it was generally advisable
to postpone its use for a day or two. Employing the catheter too soon means
leaving it in position longer than intended. Thus, a urethritis is set up which
could have been avoided. Any question of the fistula becoming epithelialized
in the meantime was safeguarded by curetting it with a sharp spoon, while the
drawing together of the edges of the wound with adhesive plaster was helpful
in bringing about closure in many cases.

Before final closure of the fistula can be precipitated by the use of an
indwelling catheter, it is necessary that the wound surface be free from slough
or phosphatic deposit, and that micturition be re-established.

These factors being present, then the most favourable time is when the
fistula remains dry for an hour or more at a time. In such cases closure from
an indwelling catheter can be relied upon. On the other hand, it may be said
that once a case has reached the “ wet and dry ” stage spontaneous and
final closure is imminent, and the catheter is not required. This was certainly
so in some cases, but in several in which an indwelling catheter was contra¬
indicated for other reasons the fistula, in spite of these indications, remained

122 White: Closure of the Suprapubic Urinary Fistula

open for a considerable time subsequently. The plan therefore followed was
to resort to the indwelling catheter, if spontaneous closure had not occurred
after several days of this stage, provided there was no contra-indication for so
doing.

Where the spontaneous onset of micturition was delayed it was essential to
resort to this procedure. In some, this was done when micturition had not
commenced by the twenty-first day; but in no such case did final closure of
the fistula result after removal of the catheter until it had been used a second
time following a week’s interval of rest for the urethra.

Fistulae most obstinate in closing even after the use of an indwelling
cathether were noted in the following cases : (l) After the second stage of
prostatectomy, where preliminary cystostomy had been performed several
months previously, and where a cicatrized fistula remained ; (2) where re¬
establishment of micturition did not occur until after the use of the indwelling
catheter.

The catheters employed were gum elastic coud6, ranging from Nos. 18
to 22 (French scale). The largest size was always used where possible, as it
provided the best drainage. It was seldom that one so small as a No. 18
had to be used, and, when so, always required a good deal of attention, as the
narrow lumen easily became blocked. When this occurred, the only satisfactory
way to deal with it was to remove it and replace it by another. Obviously,
all the good intended from the catheter may be lost if it is allowed to remain
blocked for several hours, as the increasing intravesical pressure may cause the
fistula to re-open. It was an essential for the success of this part of the treat¬
ment that frequent inspections and irrigations were made.

(4) The Operative Procedures.

These embraced three types of operation: (1) Freyer’s operation; (2)
Thomson-Walker’s operation ; (3) two-stage prostatectomy.

Eighty-one per cent, were dealt with by one or other of the first two
methods, and on an average the fistulas in these cases closed on the twenty-
sixth day. In the remaining 19 per cent, of cases, prostatectomy was per¬
formed in two stages, the fistulae closing on an average on the thirtieth day,
but the slower cases were by no means all in the last group.

With the more tardy cases the question naturally arose whether the delay
was due to any obstruction to the outflow from the urethra. In a number of these,
on a metal sound per urethram being passed, an obstruction could be made out
between the prostatic cavity and the bladder [7]. In all of these cases Freyer’s
operation had been performed. As it did not fall to my lot to pass the sound
in all cases I cannot give the actual figures.

In two-thirds of the total number of cases operated upon Thomson-
Walker’s operation [8] was performed, which entirely eliminated the possibility
of obstruction.

In the two-stage cases the intervals between the cystostomy and the
removal of the prostate covered periods varying from two weeks to eight
months. In two cases the patients underwent prostatectomy as long as eight
months after cystostomy, and as would be expected in each case the fistulous
track was considerably fibrosed at the time of operation. One took eight
weeks and the other nine weeks to close.

Section of Surgery

123

(5) The Onset of Micturition.

Except in several exceptional cases, micturition did not recommence until
several days after the suprapubic drain had been removed. The practice fol¬
lowed was to remove the drain on the tenth day unless there was an indication
for continuing the drainage a little longer. As stated by Sir John Thomson-
Walker in his boob [9] : “ Occasionally there is a rise of temperature when
the patient first passes urine through the urethra, but this subsides on the
following day.” This was noted in a number of cases. The actual figures
with regard to the times of onset of micturition are shown in Table II (p. 125).
In one case micturition was as late as the thirty-fourth day in commencing,
and only after the use of an indwelling catheter. In two cases micturition
was established on the day following removal of the suprapubic drain.

In backward cases, the use of the indwelling catheter undoubtedly helped to
establish the habit. In one, however, it was not successful until after the use
of the catheter for the second time. It was demonstrated that the slow return
of micturition was one of the most important factors in connexion with delay
in closure of the fistula. It must be obvious that the final closure of the
fistula is impossible until micturition is re-established. Moreover, acute re¬
tention occurred in two cases in which the fistulas suddenly closed before
micturition had commenced. They were treated with the indwelling catheter.
With regard to the causes of the late onset of micturition, it was found
that in two cases some obstruction to the passage of a sound was manifested
between the prostatic cavity and the bladder. In about 90 per cent, of those
cases, however, with micturition delayed towards the end of the fourth week,
there was one or other of the two following factors present in the history : (l)
Symptoms of enlarged prostate for several years ; (2) marked chronic retention
of recent origin. The inference is that loss of tone of bladder muscle from
chronic retention was the chief cause of delay.

(6) The Time of Removal of the Suprapubic Drain.

In seven of the earliest cases of the series the drainage-tube was removed
on the seventh day. The motive in early removal was the hope of thereby
shortening the convalescence. The average number of days before final closure
of the fistulas in these cases was twenty-eight; whereas the average for a similar
number of cases in which tubes were removed on the tenth day, being treated
at the same time, was twenty-one; thus the object of early removal appears to
have been defeated. It is undoubtedly an advantage to continue the drainage
until the granulations in the prostatic cavity are well formed. There was a
very striking tendency to unsteadiness in the temperature in those cases in
which early removal was practised. Freyer [10] points out that patients
who pass urine early in the convalescence often do badly.

(7) Secondary Hemorrhage.

This occurred in four cases, about 6 per cent. In each case, owing to the
state of the urinary tract, the patient was a poor subject for operation.
The bleeding occurred at varying periods between the eleventh and the
twentieth days. In no case was the haemorrhage so severe as to cause
any real anxiety. Each was treated by displacing the clots from the bladder
with irrigation by Janet’s method, after dilating the fistula so that the larger

124 White: Closure of the Suprapubic Urinary Fistula

size tube could be replaced, and this was left in position until all signs of
bleeding had ceased. It is important to recognize that to deal effectively
with this complication the bladder must be emptied of clot; otherwise the
contractions set up by its presence will cause the haemorrhage to continue.
Haemostatic serum and morphia, hypodermically, were useful adjuncts.

(8) Malignant Cases.

There were seven of these, 10 per cent, of the total. All were early and
recognized clinically before operation, except one, and all offered some prospect
of relief by prostatectomy. In two cases the enucleation was accomplished
with the forefinger. In the other five cases* the removal was only completed
by sharp dissection, after the patient had been placed in the Trendelenburg
position. The average number of days in closing for six of these was
twenty-one. The other case was discharged with a permanent suprapubic
drain.

Although the fistula in six of these cases closed so readily, five of the
patients reported back to hospital within a few months with the fistula
re-opened.

(9) Summary.

(1) Too early removal of the suprapubic drain, by diminishing the drainage
too soon, tends to delay the convalescence. Rapid closure of the fistula is not
always desirable.

(2) Closure of the suprapubic fistula without an indwelling catheter should
be the aim in all cases. This was accomplished in about 52 per cent, of the
cases.

(3) The indwelling catheter is necessary in a large proportion of cases,
to avoid an unduly protracted convalescence. It was employed in about 48
per cent.

(4) The indwelling catheter does not help the fistula to close if used too
soon ; it increases the amount of sepsis present if left in too long.

(5) No complication arose from its use for three successive days in any*
case of this series.

(6) In a considerable majority (about 66 per cent.) the fistulas were finally
closed either with or without the aid of an indwelling catheter by the end of
the fourth week.

(7) In the remaining cases the chief causes of delay in closure were:
(a) Complications preventing the use of an indwelling catheter, such as
acute epididymitis and pyelonephritis; (6) delayed onset of spontaneous,
micturition, most commonly in cases of previous chronic retention; (c) long¬
standing suprapubic fistulae in two-stage prostatectomy cases; (d) a shelf of
mucous membrane between the bladder and the prostatic cavity, in some cases
after Freyer’s operation for prostatectomy.

(8) The fistulse in malignant cases may close very readily following supra¬
pubic prostatectomy, but tend to re-open within a few months.

I would emphasize, in conclusion, that I do not bring this matter forward
as a plea that any particular method of after-treatment that will hasten
the closure of the fistula is the most desirable; nor do I advocate that the
procedures followed in these cases should always be practised, knowing that
there are alternatives which are equally efficient. But in realizing the
importance of ascertaining the results of treatment in a considerable number
of cases by any given method, I have stated the foregoing facts in the hope
that their permanent record may prove of some value.

Section of Surgery

125

Table I.—Division of Cases into Groups in Relation to the Employment
of an Indwelling Catheter.

Group J.

All cases whose fistula were finally closed by the twenty-eighth day of convalescence,
without an indwelling catheter:—

26 cases ... ... ... ... ... ... 88 per cent, approx.

Average time for fistula to close ... ... ... 20 clays

Group II.

All cases showing signs of delay in closure of fistula :

{a) Treated with an indwelling catheter :

28 cases ... ... ... ... ... ... 41 per cent, approx.

In 19 cases fistula closed by the twenty-eighth day.

In 9 cases fistula closed after the twenty-eighth day.

( b ) Indwelling catheter contra-indicated for time being:

18 cases ... ... ... ... ... ... 20 per cent, approx.

In 8 cases fistula closed spontaneously in due

course : Average time in closing ... ... 87 days

In 5 cases fistula closed after postponed use of

indwelling catheter: Average time in closing... 34 days

Table II.—The Time of Onset of Micturition.

For whole series, the average day of convalescence was the nineteenth.

In 60 per cent, spontaneous onset by the twenty-first day.

In 25 per cent, spontaneous onset between the twenty-first and twenty-eighth day.
In 14 per cent, onset only after indwelling catheter.

REFERENCES.

[1] Freyer, Sir P., “Enlargement of the Prostate,” 1920, p. 67. [2J Freyer, Sir P., Ibid. y

p 68. [3] Janet, “ Technique des Lavages sans Sonde de PUrfetre,” Journ. d' Urol. MM. et Chir .,

Paris, pp. 647-650. [4J Winsbury White, “Epididymitis and Suprapubic Prostatectomy. A

Study of 50 Cases.” Lancet , 1922, i, p. 821. [5] Deaver, “ After Care in Suprapubic Prostatec¬
tomy,” Amer. Journ. Surg ., July, 1920. [6] Marion, “ Trait6 d’Urologie, 1921, ii, p. 1024.

[7] Thomson-Walker, Sir J., “ Hiemorrhage and Post-operative Obstruction in Suprapubic
Prostatectomy; an Open Operation for their Prevention," Brit. Journ. Surg ., 1920, vii, p. 525.
[ft] Thomson-Walker, Sir J., “ Genito-urinary Surgery,” 1914, p. 712, Cassell and Co. [9]
Thomson-Walker, Sir J., Ibid. [10] Freyer, Sir P., “Enlargement of the Prostate,” 1920*
p. 74.

PROCEEDINGS

OF THE

ROYAL SOCIETY OF MEDICINE

EDITED BY

Sir JOHN Y. W. MacALISTER

UNDER THE DIRECTION OF

THE EDITORIAL COMMITTEE

VOLUME THE SIXTEENTH

SESSION 1922-23

SECTION OF THERAPEUTICS & PHARMACOLOGY

LONDON

LONGMANS, GREEN & GO., PATERNOSTER ROW

1923

Section ot {Therapeutics ano pharmacology

OFFICERS FOR THE SESSION 1922-23.

President —

W. Langdon Brown, M.D.

Vice-Presidents —

Robert Capes.

A. J. Clark, M.D.

H. H. Dale, C.B.E., M.D., F.R.S.
W. E. Dixon, M.D., F.R.S.

.1. Gray Duncanson, M.B.

Sir William H. Willo

Sir William Hale-White, K.B.E..
M.D.

Fred. Ransom, M.D.

Ralph Stockman, M.D.

F. Parkes Weber, M.D.

, K.C.I.E., C.B., C.M.G., M.D.

Hon. Secretaries —

Philip Hamill, M.D.
J. H. Burn, M.D.

Other Members of Council —

A. Geoffrey Evans, M.D
Dorothy C. Hare, M.D.
C. O. Hawthorne, M.D.
Orlando Inchley, M.D.

Edward Mellanry, M.D.
Nathan Mutch, M.D.

J. W. Trevan, M.B.
Cecil Wall, M.D.

Representative on Library Committee —
E. P. Poulton, M.D.

Representative on Editorial Committee —
George Graham, M.D.

SECTION OF THERAPEUTICS AND
PHARMACOLOGY.

CONTENTS.

October 10, 1922.

W. Langdon Brown, M.D. (President). cage

The Problems of Asthma ... ... ... ... ... ... 1

T. Izod Bennett, M.D.

The Modification of Gastric Function by means of Drugs (Abstract) ... ti

November 14, 1922.

E. Boock, B.Sc., and J. W. Trevan, M.B.

The Effect of Light on the Response of Frogs to Drugs ... ... H

January 9, 1923.

DISCUSSION ON “THE PRESENT POSITION OF ORGANOTHERAPY.”

Professor Swale Vincent. D.Sc., M.D. (p. 9), Dr. George R. Murray (p. 14).

Dr. W. R. Grove (p. 18), I)r. H. Vinks (p. ‘23 \ Professor W. E. Dixon, F.R.S.

(p. 23), Dr. W. Langdon Brown (President) (p. 23)

March 13, 1923*

DISCUSSION ON THE ACTION OF QUINIDINE IN CASES OF CARDIAC

DISEASE.

Professor Francis R. Fraser, (p. 25), Dr. A. X. Drury (p. 30), Dr. A. E. Clark-
Kennedy (p. 32), Dr. T. F. Cotton (p. 38). Dr. F. Parkks Wkker <p. 4(b,

Dr. B. T. Parsons-Smith (p. 41).

April 10, 1923.

B. Hamilton Kirk. M.R.O.V.S., Captain R.A.V.C.

The Idiosyncrasies to Drug Tolerance of Animals as compared with Man 43

Contents

SECTIONS OF OBSTETRICS AND GYNECOLOGY,
THERAPEUTICS AND PHARMACOLOGY.

(JOINT MEETING.)

December 7, 1922.

H. H. D alb, C.B.E.. M.D.. F.R.S. paois

The Value of Ergot in Obstetrical and Gynaecological Practice; with

Special Reference to its Present Position in the British Pharmacopoeia 1

Discussion: Sir Nestor Tirard, Dr. Herbert Spencer, Professor W. E.
Dixon, F.R.S., Dr. T. W. Eden, Mr. Aleck Bourne, Professor H. Briogs,

Dr. Dale (reply), pp. 5-7.

The Society does not hold itself in any way responsible for the statements made or
the views put forward in the various papers.

.1 1 ill m Il;t!»*. Sun' A I>:nn«‘l- vun, -Hi, (Jpit TltHifield l.omloil, W I.

Section of Gberapeutics anb pharmacology.

President—Dr. W. Langdon Brown.

The Problems of Asthma :

PRESIDENT’S ADDRESS.

By W. Langdon Brown, M.D.

In pursuance of my conception of the functions of this Section, I have
chosen as the subject of my address one which has both clinical and experi¬
mental aspects. The problems of asthma were for years most baffling, but
recent work has cleared the ground and defined the issues. These problems
have now revealed themselves as involving subjects of most topical interest—
psychotherapy, sensitiveness to foreign proteins, vagotonia and endocrine
balance. The treatment of asthma summarizes in itself, as it were, the chief
trends of modem therapy. But there has been a tendency on the part of
enthusiastic workers in some one of these fields to neglect due consideration of
the other aspects. Successful treatment involves them all.

It is always a dangerous thing to try to express a disease in a formula.
Nevertheless, I attempted to do so for asthma not long ago. 1 Hurst* has
recently improved upon that formula, and I accept his emendation gladly. He
has defined asthma as due to an unstable or irritable condition of the broncho-
motor portion of the vagus nucleus, which causes it to react unduly to psychical
or peripheral stimuli, or to foreign proteins in the circulating blood. I think
this could still be modified with advantage by including the obvious vasomotor
turgescence which accompanies the bronchomotor spasm, as this is always
present, and is sometimes the most striking feature of an attack, just as it is
in the closely allied condition of hay fever. Moreover, it is carried out by the
same vagal mechanism. Thus modified the formula can be expressed
diagrammatically as follows:—

| Psychical
• stimuli

Peripheral stimuli--nucleus-^-Foreign proteins

Bronchomotor spasm <— 1 -Vasomotor turgescence

i Clin . Journ. t July 7,1920, xlix, p. 97.

- New York Med. Joum ., March 15, 1922, p. 347. In the Lancet , 1921, i, p. 1113, Hurst gives a
definition practically identical with the one here suggested.

Ja—Th 1

[October 10, 1922.

Langdon Brown: The Problems of Asthma

I will first consider the stimuli acting on the centre, and then some features
of its response.

(1) Psychical Stimuli .—That asthma often occurs in neuropathic families,
and that asthmatics are unduly suggestible, are well-known facts. The
paroxysm excited by an artificial flower figures in every text-book. But it is
extraordinary to witness the almost instantaneous relief that may follow a
hypodermic injection of distilled water into a patient who is anticipating one
of adrenalin, when this is known to be efficacious. It makes me wonder how
much of the success of single minim doses of adrenalin are due to suggestion
and how much to the drug. At any rate, it explains why the asthma curer who
has profound belief in the efficacy of his treatment finds increasing justifica¬
tion for that belief. For his confidence arouses responsive confidence in his
patient. But what is not so clearly recognized is that the effective stimulus
often arises from a psychic conflict. Such a conflict may express itself at
the psychic level of the nervous system as an obsession or a phobia, and
at the sensori-motor level as a paralysis, a tic, a contracture or an anesthesia;
while if it sinks deeper to the visceral level it may express itself as glycosuria,
exophthalmic goitre or asthma. Naturally other influences will help to decide
in which of these ways the psychic trauma reveals itself. Thus, one sufferer
from a psychic conflict who has to face a hostile environment may escape
through an hysterical paralysis, but another who has to face the internal
disorder produced by sensitiveness to foreign proteins is more likely to
develop asthma.

(2) Peripheral Stimuli .—I have little to add to the common stock of
knowledge of this subject. The influence of eyestrain, hay fever and other
nasal troubles, sinus infection, gastric and intestinal disturbances, and of uterine
disorders is well recognized. But I should like to call special attention to
enlarged bronchial glands, especially in children, and to suggest that this may
explain the liability of healed tuberculosis to excite asthma in susceptible
subjects. Interesting observations by Baccarini show that peripheral irritation
of the pleura, such as paracentesis, may excite an attack of asthma. In the
epileptic a fit can be similarly produced, which leads him to compare bronchial
spasm to a localized epilepsy. Other points of resemblance between epilepsy
and asthma will readily occur to you.

Foreign Proteins .—Of recent years great attention has been paid to this
factor. Morley Roberts has made the profound remark that “ immunity is
assimilation.” There is one flesh of birds and another of beasts. From the
welter of amino-acids which result from the disintegration of food proteins each
animal has to build up its own characteristic and specific tissues. Specificity
is chemical as well as morphological. To some foreign proteins we are
naturally immune, i.e., we can assimilate them automatically; to others we
acquire immunity, i.e., we learn to assimilate them. But to some foreign
proteins immunity is neither congenital nor acquired. The tissues continue
to resent the intrusion of such. They will not assimilate them. Such pro¬
teins excite anaphylaxis in varying degrees. Richet has defined anaphylaxis
as the last stand of the race against adulteration of its protoplasm. In extreme
degrees anaphylactic shock is fatal because assimilation would mean too pro¬
found an alteration of bodily structure. In less degrees anaphylaxis declares
itself in violent attempts to get rid of the foreign invader. As Drury 1 has
expressed it, the toxic idiopathies are conservative, self-repairing mechanisms
under parasympathetic control.

1 Med. Joiim. South Africa, 1921, xvii, pp. 66-74.

Section of Therapeutics and Pharmacology

The Influence of the Parasympathetic .—The great function of the para¬
sympathetic may be defined as promoting the assimilation of suitable and
the rejection of unsuitable material. Thus it starts the secretory and
muscular processes of digestion, while it empties the rectum and bladder, and
can reject food by vomiting. The excitation of bronchial catarrh and cough
is similarly a method of ridding the body of unsuitable material, and it is
interesting to recall in this connexion that drugs which are expectorant in
small doses are emetic in larger ones. The similarity of the parasympathetic
action on the alimentary and respiratory tracts is not surprising when we
remember that the latter tract develops as an outgrowth from the former.
The vagal factor in normal respiration may indeed be defined as a mechanism
for insuring the alternate taking in of assimilable oxygen and the rejection of
unnecessary CO 2 . Confronted with an irrespirable gas the vagus checks its
entrance to the lungs by laryngeal spasm. But I do not think we can in this
way explain bronchomotor spasm, which, while tending to interfere with
elimination, does not prevent the entrance of unsuitable material. This, I
think, is an example of that exaggerated response which is so typical of patho¬
logical states. The undue irritability of the vagus centre sets up sdch a strong
efferent impulse that is not confined to the vasomotor channels, but overflows
along the bronchomotor fibres.

Without accepting the whole of Eppinger's and Hess’s theories we may agree
that the asthmatic is a vagotonic, and is liable to other manifestations of vago¬
tonia. I recently had a curious instance of this in a man who suffered from
both asthma and gastric ulcer, and who had found out for himself that he could
relieve the pain of his ulcer by smoking a stramonium cigarette. And I should
agree with the description which has been given of a form of mucous colitis
as “ asthma of the colon.”

The Sympathetic and Endocrine Balance .—But vagotonia may be relative
as well as absolute. In other words, it may well be that an overacting vagus
is due to diminished action of the antagonizing sympathetic. One of the ways
in which the sympathetic carries out its defensive function is by activating
those endocrine glands which flood the blood with sugar, thus increasing
metabolism and exciting a febrile response. Lest this excess of sugar
should be wasted by overflowing into the urine, the threshold of the kidney
is raised in fever. But the febrile response is not the only way in which
immunity is acquired. One of the greatest gaps in our knowledge at the
present time is our almost total ignorance of the part played by the endocrine
glands in immunity. Beyond the fact that thyroid extract may increase the
yield of amboceptors, following the injection of an antigen, we know hardly
anything on this point. Yet I feel that further research will show that just
as anaphylaxis is associated with vagotonia, the opposite condition of sym¬
pathicotonia is related to immunity through the endocrine system. Not
infrequently hypo-adrenalinism follows or accompanies anaphylaxis, and
certainly adrenalin has a valuable action in anaphylactic shock. It has
a similar effect in some cases of urticaria (Harrower). Hurst 1 considers
that the toxic idiopathies, including asthma, produce their effect, at any rate
in part, by depressing adrenal activity. He believes that the influence of
fatigue in inducing the asthmatic paroxysm is capable of a similar explanation.
Morley Roberts suggests that so might be the apprehensiveness so common
in asthmatics. The overactivity of the broncho-constrictor fibres of the vagus

1 Loc. cit.

Langdon Brown: The Problems of Asthma

is kept in check by the broncho-dilator action of the sympathetic, which the
secretion of adrenalin would stimulate. Hence the effect of an injection of
adrenalin, or of sudden fright in checking an attack of asthma. Asphyxia
has a similar action and produces the same effect; no doubt it is thus a
factor in bringing the attack to an end without a fatal issue. I am aware
that Stewart and Kogoff deny this emergency action of adrenalin, but
Cannon's 1 recent experiments have disposed of much of their purely de¬
structive criticism. The liability of asthma to come on during sleep, when
the parasympathetic gains the upper hand, further points to the influence of
disturbed balance between the two great branches of the visceral nervous
system. The reinforcement of the adrenalin effect by pituitrin may be held
to point in the same direction. The glands which co-operate with the
sympathetic appear generally to help in checking the asthmatic paroxysm.
The stimulating effect of the gonads in the sympathetic-endocrine group may
account for the influence of uterine disease in exciting asthma. It must be
admitted, however, that it is difficult on this hypothesis to explain why asthma
is liable to appear at puberty and to be aggravated by pregnancy, when the
thyroid and pituitary are stimulated, unless it is that some asthmatics have a
gonadal deficiency which declares itself in this way. Certainly gonadal
deficiency may be associated with thymic asthma, which is comprehensible
since the thymus is an infantile organ, apparently antagonistic to the
gonads. Recently I saw a case of what appeared to be thymic asthma in
a stout girl aged 17, with amenorrhoea. Treatment with an ovarian extract
was sufficient to stop the attacks. No element of suggestion came in
here, for she did not know what she was taking. In general terms, it
would appear that when the endocrine balance sways in the direction of
the vagus, asthma is likely to occur in susceptible subjects ; when the balance
is redressed in favour of the sympathetic attacks may be cut short or
prevented.

Asthma , Anaphylaxis and the Skin .—The skin undoubtedly has excretory
functions. I recently had a severe and ultimately fatal case of uraemia, which
first manifested itself by a marked toxic erythema. Urea was greatly increased
both in the blood and cerebro-spinal fluid while in the cerebro-spinal fluid other
amines were demonstrated to the extent of 0*24 per cent. The rashes of the
exanthemata have often been compared with that produced by serum in
anaphylactic subjects. This conception of an excretory mechanism is expressed
in the popular idea of the benefit derived by “ getting the rash out.” The toxin
which cannot be assimilated, i.e., to which the body is not immune, must be
got rid of somehow, and at any rate from the vital structures. In this
connexion it is interesting to note the occasional alternation of attacks of eczema
and asthma. The following family tree which came under my notice is a
striking example of this alternation in different members of the family:—

Eczema

Asthma

Eczema

<? 2 <? 2
Eczema Eczema Laryngismus Laryngismus

stridulus stridulus

1 t fount. Mcnt. Xerr. 1)ix. y 1921. liv, p. 421.

Section of Therapeutics and Pharmacology

The condition of laryngismus stridulus is recognized as the infantile
equivalent of asthma. It is further of interest to recall that both in skin
diseases and in asthma eosinophilia is a usual feature of the blood picture.
As an attack of asthma goes on and expectoration becomes more abundant,
the eosinophils pass into the sputa. I should regard the skin reaction of an
asthmatic to foreign proteins as an attempt to wash out the offending non-
assimilable material from the skin. I was proceeding to look for the occurrence
of eosinophilia in the urticarial wheals produced by this test, when
Dr. Mackenzie Wallis informed me he had already observed it. I think
this all accords with the observations of Kanthack and Hardy, thirty years
ago, on the r6le of eosinophilia in bacterial infections and intestinal digestion,
which have passed into undeserved oblivion.

Treatment.

These considerations help to provide a rational explanation for some
methods of treatment which have been empirically used in the past. I hope
also that they may help to co-ordinate the views of those working at different
aspects of the problem, and to emphasize the necessity for all-round assault on
every case of asthma from these various aspects. For some, asthma is merely
a psychological problem ; but that is to close one's eyes to the toxic factor. For
others the toxic element is the primary thing, the nervous factor being merely
the failure of the nervous system to co-operate successfully in getting rid of the
toxin. This view has been well-expressed by Morley Roberts thus : “ Why is
there a spasm ? What is the spasm but violent overacting surface tension
pulling every cell in the small bronchi and alveolar spaces into its least form,
as it tries to squeeze out irritants, tries to defeecate, so to speak. The
sympathetic and parasympathetic rush in to aid. There is a tendency to over¬
rate nervous action. Cells live their lives, have their disasters, even without
nervous interference except in stress, as they did in the beginning." But this
view is not capable of explaining the influence of suggestion in actually
producing a paroxysm in the absence of the exciting toxin. The suggestibility
of the patient should be utilized to help him confidently to expect a cure.
The effect of climate may often be due to suggestion. An asthmatic goes to a
place and has an attack: therefore each time he goes there he expects to have
one, and has it. The converse is also true. To point this out in the former
instance may help him to avoid repetition. But search must also be made
for deeper-seated psychological troubles. Naturally sources of peripheral
irritation must be eliminated; this includes avoidance of late suppers and
cold bedrooms. The skin reactions are in my experience very helpful
in determining the foreign proteins to which the patient is sensitive.
Not only in asthma should this be tried; it is worth trying in any vago¬
tonic with toxaemic symptoms. I recently had a striking example of this
in a patient who was emaciated and profoundly depressed, but whose chief
objective trouble was a painful swelling of the tongue and lips. Dr. Mackenzie
Wallis kindly tested his skin reactions and found he was highly sensitive to
cereals. In addition to other simple measures cereals were removed from
his diet, and he was allowed many things which had formerly been prohibited
in the belief that he had gout. The effect was dramatic ; in one month he put
on 16 lb. in weight. Only yesterday I received a letter from his medical man
in the course of which he says : “ I think his almost daily progress has been
one of the most marked and interesting cases I have had under my observation
for a long time. Socially he is entirely altered . . . bright and entertaining

6 Langdon Brown: Asthma; Bennett: Gastric Function

and his old-fashioned courtesy has returned. In fact he is so far a complete
revolution and revelation.” An experience like that gives one “ furiously to
think ” of the toxic factors we must often overlook in cases diagnosed as
neurasthenia, or “functional/' Where the offending protein cannot thus
be eliminated we should consider what methods of desensitization are feasible.
I should like to add that in my experience it is most important to exclude the
syphilitic toxin as the offending protein. I saw a case in a woman, aged 40,
who had asthma during her last pregnancy ; she was delivered of a macerated
foetus and her Wassermann reaction was strongly positive.

The universal belief in the efficacy of the belladonna group in asthma finds
its justification in the paralysing action of such drugs on the parasympathetic
endings, just as the fillip given to the sympathetic by adrenalin or cocaine
helps to redress the balance in another way. According to some, the influence
of iodide is mainly to activate the thyroid: if this is so the benefit of this drug
in asthma is comprehensible, since the thyroid secretion lowers the threshold
to sympathetic stimulation. But so far we have no explanation of the way in
which arsenic acts in this disease, though certainly it often seems to help.
The importance of doing everything we can to restore an impaired endocrine
balance is, I think, undoubted.

This all-round attack on the problems of asthma seems to me to afford the
best chance of relief, especially if carried out before structural changes such as
emphysema have occurred. After that a vicious circle is set up which is hard
to break.

The Modification of Gastric Function by Means of Drugs,
By T. Izod Bennett, M.D.

(ABSTRACT.)

[This paper will be published in full in the British Medical Journal .]

In no branch of medicine is the difference between the list of remedies
used in practice, and that approved by pharmacologists as having definite
actions, more noticeable than in the branch which deals with gastric disorders.
Recent researches do enable us to point to certain substances as being proved
experimentally to have definite effects, and they may best be classified into:
(I) Those affecting gastric secretion ; and (II) those affecting gastric motility.

(I) Substances affecting Gastric Secretion.

(a) Diminishing Gastric Secretion : Atropine .—Medical literature shows an
entire lack of agreement as to the potency of atropine in arresting gastric
secretion, but the author has found its effect to be very marked. Especially is
this so if the drug be used as a wash to the mucous membrane; curves
of fractional gastric analyses were exhibited illustrating this ; and the author
gave it as his opinion that the effect of weak atropine solution on the gastric
mucosa was as powerful as its effect when applied to the eye. In practice he
had found atropine in great dilution a valuable remedy when given on an
empty stomach.

(b) Increasing Gastric Secretion : Pilocarpine. —Pilocarpine applied locally
is correspondingly less effective, because though, as shown by fractional

Section of Therapeutics and Pharmacology

gastric analysis, it excites secretion by the gastric glands, it is rapidly absorbed
and will then cause profuse salivation which frequently dilutes the total gastric
contents and so lowers their acidity.

(c) Substances affecting the Gastric Secretion after its Evolution: (i) Sub¬
stances Neutralizing Acid Secretion .—Having Referred to the controversies as
to the actual effects of the alkaline salts in cases of hyperacidity, the author
showed curves of fractional gastric analysis which demonstrated the increase
in secretion produced by bicarbonate, and the complete but temporary neutral¬
ization produced by magnesium hydroxide if administered after a meal.
Summarizing the results of recent experimental work he said:—

(1) That sodium bicarbonate tends to excite the gastric mucosa to increased
secretion and that this effect more than counterbalances its neutralizing
effects.

(2) That magnesium hydroxide and bismuth carbonate are less stimulating
and stronger in their neutralizing effects.

(3) That all such salts should be given after meals.

(4) That for arresting secretion atropine is much the most effective
substance.

(5) That the true indication for sodium bicarbonate is in those cases with
low acidity which show an excessive secretion of mucus.

(ii) Substances replacing Deficient Acid Secretions. —The author referred
to the functions of HC1 in the stomach, and pointed out the necessity of
giving large doses if an effect were to be produced. Recent work has shown
that in normal circumstances any added HOI is neutralized by duodenal
regurgitation. Reference was made to the very potent action of HOI on
bacterial growth.

(II) Substances affecting Gastric Motility.

Having briefly referred to the modern work on the bitters, which has failed
to show any gastric effects arising from the ingestion of these substances, the
author discussed drugs which may influence gastric motility. He said that
atropine does not usually produce any marked effect, but that in cases of
gastric spasm it may be of great use. He compared its action in such cases
to that of the digitalis series when they are employed for producing heart-block
and checking tachycardia in cases of auricular fibrillation. For increasing
gastric motility pilocarpine has been employed, but its effect was not marked
unless dangerous doses were employed.

The recent work of Berti on strychnine was then described, a series of
radiographic tracings being shown which demonstrated the effects of this drug
on the stomach. Only in very small doses—less than 1 mgr., by mouth—can
this drug be shown to cause more rapid emptying of the stomach; in larger
doses an initial increase in peristalsis is followed by rapid tiring, with
production of spastio contraction in the pyloric region. With large doses
hour-glass constriction of the stomach is produced. The author emphasized
the importance of employing only small doses of this drug in gastric cases.

In conclusion, reference was made to a series of experiments with adrenalin ;
although emotional states such as fear can readily be demonstrated to delay
the emptying of the stomach the author had been unable to produce such
effects with adrenalin. A large number of observations had been made, the
drug being given both hypodermically and as a wash, but the effects both
on gastric secretion and gastric motility has been negative.

8 Boock and Trevan: Effect of Light on Response to Drugs

The Effect of Light on the Response of Frogs to Drugs.
By E. Boock, B.Sc., and J. W. Trevan, M.B.

(From the Wellcome Physiological Research Laboratories.)

FROGS {Bana temporaria) exposed to light on a white background until
yellow, succumb to much smaller doses of members of the digitalis series than
frogs which have become dark coloured by being shielded from light. Frogs
vary in the rate at which they change colour. A yellow frog will occasionally
remain yellow for some hours in the dark, and such a frog remains more
susceptible to digitalis in the dark than a black frog. Black frogs more often
die out of order in digitalis testing than do yellow frogs. The lethal dose for
the black frog is about 1*75 times that for the pale frog.

Frogs rendered yellow by the injection of adrenalin 0*5 c.c., 1/10,000 per
20grm. frog, are also more susceptible to digitalis than black or medium tinted
frogs, while frogs rendered black by injection of extracts of the posterior lobe
of the pituitary are less susceptible than controls.

The effect in this case is not due merely to alteration of absorption, for
the lethal dose of digitalis when injected intravenously is affected in the same
way by the administration of adrenalin or pituitary in pithed or intact frogs.

Macht 1 showed that quinine, when injected into frogs exposed to light,
killed in smaller doses than when the frogs were kept in the dark. He
attributed this result to an alteration of the quinine by the light—quinine
being a fluorescent substance and absorbing the ultra-violet rays. We have
tried the effect of pituitary extract and adrenalin on the minimal lethal dose of
quinine, and find that, just as with digitalis, yellow frogs are more susceptible
than black, this suggesting that a part at least of Maoht’s effect is an alteration
of the frog and not of the quinine.

Hogben and Winton 2 suggest that the change of colour in frogs in response
to light is mediated by pituitary or adrenalin secretion and our results are at
least not a contradiction of this view.

These experiments suggest that when considering the mode of action of
light on mammals, which is arousing so muoh interest at the present time,
it would be well for us to bear in mind the possibility that the metabolic
changes in mammals are not due to a photochemical synthesis in the skin, but
to an action resulting from the stimulation of light-sensitive nerve endings in
the skin or the retina, with the consequent reflex alteration of metabolism
similar to that found in the experiments described above.

Biedermann 8 claims to have shown that the receptors for the light reflex
in the frog are situated in the skin of the animal.

i Proc. Soc, Exp. Biol, ami Med. t 1922, xix, p. 397.

- Proc. Roy. Soc., 1922, B, xciii, p. 318.

:i Pfluger’s Archiv f. d. ges. Physiol 1892, li, p. 457.

[November 14, 1922.

Section of Gberapeutic* anb pbarmacoloQp.

President—Dr. W. Langdon Brown.

DISCUSSION ON “THE PRESENT POSITION OF
ORGANOTHERAPY.”

Professor Swale Vincent, D.Sc., M.D.

It has sometimes been maintained that in therapeutics as in other matters,
only those materials and those methods which are found to be useful and
beneficial will ultimately survive. In the ordinary practical affairs of life this
anticipation may be well founded, but in such a matter as the employment of
various substances to relieve pain, or to restore to the normal the deranged
machinery of life, it would seem that we cannot even yet trust either the
scientific discrimination of medical men or the common sense of the general
public to eliminate the useless and to hold fast to that which is good. The
reasons for this suspicion will be stated in due course.

At the present time many physicians are in the habit of prescribing thyroid
and parathyroid extracts, pituitary preparations of various kinds, numerous
adrenal substances, and material derived from the digestive glands, the repro¬
ductive organs, the thymus, lymph glands, prostate, mammary gland, and the
pineal body. Less frequently extracts of nervous, muscular, and other tissues,
are employed. It is not unusual to recommend various mixtures of glandular
extracts. 1 In brief, the doctrine and practice of organotherapy involve the
therapeutic use of practically every organ and tissue in the body. The belief
in the efficacy of all these substances is based upon a widely current view in
regard to the internal secretions, namely, that all organs and tissues in the
body manufacture and pour into the circulation substances the function of
which is to regulate the activities of different parts of the nervous system,
and, either through this system or in some other way, to influence the general
metabolic activities of the animal economy. If any of these be lacking or
deficient, what is easier than to replace them by administering preparations
containing them? This general theory has many ramifications and complica¬
tions. The untenable hypothesis that the secretion of the chromaphil tissues
maintains or helps to maintain the tone of the blood-vessels and the normal
blood-pressure, has given rise to the whole fabric of vagotonia and sympathico¬
tonia so dear to credulous physicians, and has even stimulated some imagina¬
tive authors to give names to non-existent “ hormones.”

When it became clear that physiological experiments lend no support to

1 One of the most recent and perhaps tlu* most foolish of such preparations is a combination of
desiccated pancreas, tonsil, and duodenal mucosa, to be taken by the mouth as a remedy for
diabetes!

My—Th 1

Jan u an) *), ll)*2:i.

Vincent: Present Position of Organotherapy

the view that all parts of the body furnish internal secretions ; when it could
no longer be maintained, with any show of reason, that the organism is liable
to suffer from a deficiency of any one or of several of these secretions; then a
large number of physicians insisted on the value of organic extracts urging
that, although they may contain no physiologically active principles, they are
found empirically to do much good in various diseases and disorders. This
attitude is difficult to criticize on a priori grounds because some few cases may
be adduced where the value of a drug has been discovered by purely empirical
means. But in the majority of the cases here referred to it has been possible
at a later period to correlate the observed therapeutic value with a definite
pharmacodynamical action subsequently discovered. It would be difficult to
mention a drug which is clearly and beyond doubt of value in the treatment
of disease and yet which possesses no known pharmacodynamical effects. It
is not necessary, I imagine, to expand this thesis, or to give illustrations.

When we turn to organotherapeutics we find a large number of substances
recommended for administration by the mouth, which, so far as can be ascer¬
tained by careful experiment, produce no physiological effects of any kind
when given in this way. When this is the case, and when physicians persist
in administering such preparations, say, of muscle or of ovary, they must be
called upon to defend their action by careful records of cases and well
authenticated instances of beneficial results.

Although extracts made from the majority of organs and tissues produce
no physiological effects when given by the mouth, yet when they are adminis¬
tered beneath the skin or into a vein some influence on the organism may be
produced. Thus, tissue extracts in general when injected subcutaneously into
dogs and cats, have a mild but noticeable stimulant or irritant action, lasting
perhaps for a few hours. When such extracts are applied intravenously the
blood-pressure may be lowered and other less obvious changes produced.
These effects, however, are not specific, and, at best, are only temporary.
The substance present in tissue extracts which lowers the blood-pressure when
introduced into the circulation has by some been supposed to be choline, by
others histamine. Its real nature is yet unknown, but we may assert con¬
fidently that it is neither of these. There may, of course, be several active
substances; some or all of them are soluble in water, alcohol, and ether. No
one has been bold enough to attempt to correlate these physiological actions
with any kind of possible therapeutic action of the extract. Or, at any rate,
the theories which bear upon this subject are so groundless, so fantastic and
so complicated, as not to deserve serious consideration. The extracts given
medicinally are recommended for reasons quite independent of the physio¬
logical action just referred to, which indeed is usually unknown to the
physician.

It is true that in addition to the thyroid and the posterior lobe of the
pituitary there may be a few instances in which feeding with an organ for a long
period may produce some effects upon the rate of growth in young animals, or
even upon the growth of special organs or tissues. Thus adrenal substance
(cortex) when administered to young growing animals seems to induce a growth
of the testis greater than in the control animals. I do not believe, however,
that there are many such instances, and such as there are can only be revealed
by the administration of very large doses and by very careful observations and
measurements. It is difficult to believe that in the present state of our know¬
ledge any result in practical therapeutics is to be derived from such findings.

In the whole province of therapeutics there are many fallacies and pitfalls.

Section of Therapeutics and Pharmacology

The ancient stumbling block, the relation between post hoc and propter hoc
looms large in our path. The apparently simple question, “ Have we done our
patient any good by the giving of this drug ? ” is often very difficult to answer.
We are all aware that many aches and pains disappear without any treatment.
And we all frequently suspect that even when medical treatment has been
adopted the subsequent recovery of the patient has had nothing to do with the
treatment—in some cases it may have occurred in spite of the treatment. It
has been aptly said “ It is a poor cure that will not find its lucky patients/'
What makes the difficulty greater is the circumstance that for various reasons
(most of which are obvious), and in the class of illness I am referring to,,
treatment is often begun just at the time when things are at their worst and
are about to return to normal. A doctor is called in the middle of the night
to see a highly nervous woman suffering from paroxysmal tachycardia. His
arrival acts as a soothing influence and he is constrained to administer some
one or more drugs from among those which are reputed to be sedatives to the
heart; but a bright idea strikes him and he gives a dose of extract of para-
thyroid glandules. No sooner has the substance passed the pillars of the fauces
than there is a sudden change for the better, and in an hour's time he leaves
his patient apparently as well as she was before the attack. Now he probably
ignores the fact that his patient was going to get better in any case soon after
the time of his arrival. He forgets the wonderful effect of the mere presence
of the doctor; he chooses to disregard the possible effects of the other drugs
and he attributes the recovery to the parathyroid extract, which, by the way,
was very possibly derived from some other tissue and not the parathyroid.
Then he publishes the case, and it will not be astonishing if he claims not only
that parathyroid extract is a useful drug in the treatment of paroxysmal
tachycardia, but that this condition is in fact due to a hypofunction of the
glandules.

It seems clear that if the value of a drug is to be ascertained and demon¬
strated something in the way of a series of experiments must be carried out.
It would be presumptuous on my part to point out precisely how a clinical
worker should conduct therapeutical experiments. It is only necessary to
remind such workers that one of the essentials in conduct of these, as indeed
of any experiments, is the institution of adequate and rigid controls. It is
obvious to any scientific reader that the endless records of single cases alleged
to be cured by this, that, or the other drug, the records of which litter our
medical journals, are not worth the paper on which they are written.

If all this is true in the realm of general therapeutics it is much truer in
the province of organotherapy.

Thyroid Medication .

Murray, in the year 1891, discovered that the administration of thyroid
substance cures myxcedema, and up to the present time thyroid material has
proved to be one of the most satisfactory drugs at our disposal. Thyroid
extract and its active principle thyroxin bring about an increase of the total
metabolism of the body. The effect is most marked where there is a deficiency
of the thyroid secretion.

There is no need to lay stress on the value of thyroid preparations in
myxcedema and cretinism. In lesser degrees of hypothyroidism {myxcsddme
fruste) there is little reason to doubt that thyroid treatment is very valuable.
The difficulty in these cases lies in the diagnosis. If the symptoms of obesity,
dryness of the skin, slow pulse, &c., are found concomitantly with a low basal

Vincent: Present Position of Organotherapy

metabolic rate, then one may reasonably hope for a good result from thyroid
treatment. In some cases of goitre thyroid extract is useful, but iodides are
more efficient in the hands of many physicians. In obesity thyroid medication
has been found to be very valuable, but if carelessly applied it may result in
much harm. Many observers state that thyroid substance does good in rheu¬
matism, rickets, mental disease, epilepsy and other conditions. It is of course
quite conceivable that a drug which stimulates the chemical activities of the
body may be valuable in a variety of conditions. If there is any good at all
to be obtained from the so-called polyglandular preparations, this is most
probably attributable to the thyroid substance contained in them.

Parathyroid Medication .

This has been used in many different conditions, but with very uncertain
effects. In tetany some good results have been reported, but oral administra¬
tion is admitted to be less beneficial than implantation. In other conditions
even the more optimistic “ endocrinologists ” confess that negative results are
usually obtained. It must be urged that there is no satisfactory evidence that
any form of tetany (except that which often occurs after operations upon the
thyroids and parathyroids) is due to a lesion of the parathyroid bodies. It
seems certain that tetany is a name applied to a condition which may arise
from a great variety of causes.

Pituitary Medication .

Eecent work on the pituitary body has compelled us to readjust our views
on the whole subject. It now seems tolerably certain that many, if not all,
the symptoms which were supposed to be due to damage to or lesions of the
organ are in reality the effects of injury to the hypothalamus. It has never
been shown that treatment by pituitary extracts has the slightest effect in
remedying the symptoms thought to be due to pituitary insufficiency. Posterior
lobe preparations have been found useful as drugs in the treatment of poly¬
uria (diabetes insipidus) and by gynaecologists to aid the contraction of the
uterus. Their influence upon smooth muscle has also led to their successful
employment in meteorism. These uses of posterior lobe preparations have,
however, no bearing on the functions of the organ. They are not instances of a
“ substitution-therapy.”

Adrenal Medication .

The value of preparations made from the chromaphil tissue of the adrenal
body is well known. Adrenin is in everyday use by physicians and surgeons.
But this value bears a very problematic relation to the function or functions of
the adrenal body as a whole, or to the services possibly rendered to the
animal economy by the chromaphil tissues. Here again, as in the case of
posterior pituitary extracts, it is not a question of “ substitution-therapy.” The
study of the physiological effects of extracts of the chromaphil tissues has led to
the employment of certain substances (amines) of known chemical constitution
and well-ascertained pharmacodynamical activity. The discovery of a certain
active substance in the tissues has served as a suggestion as to the value of
materials having a definite chemical constitution. We do not yet know the
chemical nature of the active substance contained in the posterior lobe of the
pituitary. When we do, it will not be necessary to use pituitary material
at all.

Section of Therapeutics and Pharmacology

In Addison’s disease adrenal preparations do not seem to be of the slightest
value. Transplantation of a human adrenal gland has been alleged to lead to
improvement in the condition of the patient. It seems clear, at any rate, that
adrenin produces no effects of any kind, in health or disease, when given
by the mouth, unless it be on the lining membrane of the stomach.

Testicular and Ovarian Medication .

It is more than doubtful whether extracts and preparations made from the
ovary and testis produce the slightest effect of any kind, in health or disease,
when administered by the mouth. Yet such preparations are not only ordered
frequently by medical men, but are bought and swallowed by the general public
on its own initiative. When given subcutaneously there may be observed a
mild stimulant or irritant effect, which, however, is not specific, but produced
by material from all kinds of organs and tissues. This effect has been already
referred to.

In the cases of the testis the methods of Steinach and of Voronoff ought
to be mentioned. The former ties one vas and so puts an end to the spermato-
genic functions of one testis. Then, it is alleged, the “ puberty gland,” the
interstitial tissue, hypertrophies, and its internal secretion is increased in
amount, and “ rejuvenation ” is the result. Voronoff does not think that this
method is calculated to give good results because he attributes the internal
secretion to the whole testis and not specially to the interstitial cells. And so
he recommends and carries out transplantation of testis, including both kinds
of tissue. It is too early either to appraise the value of these rival claims or
to express a positive opinion as to the results which may be expected to follow
either of the methods. It must be remembered that unless blood-vessel suture
be employed grafting is at best a temporary expedient, and that the best
results can only ensue when material from human beings or the anthropoid
apes is employed.

Pancreatic Medication .

Although it is generally recognized that the pancreas furnishes an internal
secretion, the elimination of which may give rise to a condition identical with or
closely resembling the disease known as diabetes, yet the administration of pan¬
creatic extracts has not proved to be of any value in the treatment of this disease.
This, at any rate, was the condition of affairs until within the last few months.
But quite recently a group of workers in Toronto, using an alcoholic extract,
report that they can reduce the blood-sugar level in both normal and diabetic
(depancreated) animals. Further, it is stated that the observations on dogs
have been confirmed by similar observations on several human diabetic
patients.

It will be wise not to be too sanguine in regard to these new pancreatic
preparations. But it seems probable that a step in advance has been made,
and it is not out of the question that sooner or later we may have at our service
a preparation made from the pancreas which will benefit diabetic patients in a
degree comparable with that of thyroid extract in myxoedema. The preparation
of Banting and Macleod has to be given subcutaneously. Mackenzie Wallis
claims that he has prepared a pancreatic extract by a method practically
identical with that of the Canadian investigators, and that this preparation is
effective when given by the mouth.

14 Vincent—Murray : Present Position of Organotherapy

Summary .

If we seek for cases where it is possible to apply a true substitution-therapy
—artificially to replace the internal secretion of a gland—we have no clear
instance except the solitary one of the thyroid. It may be that we shall
before long be enabled to include the pancreas in this category.

There are, however, some few instances in which extracts of organs, or
purified chemical substances obtained from them, are valuable as drugs, apart
altogether from the question of internal secretion. Such are adrenin and
extracts from the posterior lobe of the pituitary body.

Of the rest of the gland and tissue extracts and preparations, it might
perhaps be well to say nothing, if it were not their exploitation on the present-
day scale constitutes a very formidable kind of quackery. There is no subject
upon which so much utter nonsense has been talked as upon internal secretion,
and organotherapy, or at any rate a large part of it, may be defined as the
application of this nonsense to practical medicine. In the meantime certain
firms of manufacturing druggists are making the most of a unique oppor¬
tunity and are growing rich by reason of the inadequate education of medical
practitioners and the notorious ignorance of the general public on all matters
relating to their own bodies.

Dr. George R. Murray.

A discussion on organotherapy at the present time will serve a useful pur¬
pose. Certain lines of treatment by this means are based on sound physio¬
logical principles and have proved to be of great value. On this sure foundation
we must be content to build up our knowledge by reliable methods so that the
structure may be sound, and it is fortunate that this discussion has been
opened by a physiologist who has such a wide knowledge of this department of
physiology. Unfortunately, owing to the enthusiasm of some speculative
writers, a great deal of ephemeral literature has appeared, much of which is of
no value, and some has been positively harmful to the object we have
in view. The term “ organotherapy ” should be confined to the employment of
the products of the excretory, secretory and incretory glands in the treatment
of disease. Other tissues should be regarded as foods rather than drugs. The
excretory glands, from the nature of their function, do not promise much help
in this direction. Urea may be mentioned as a substance which, though not
produced by the kidney, is excreted by it, and has well known uses in medicine.
The secretory glands are those which deliver their secretion through a duct to
a surface of the skin or of a mucous membrane. The incretory or endocrine
glands are ductless and discharge their products into the blood, lymph or
cerebro-spinal fluid. Some glands, such as the pancreas and gonads, supply
both a secretion and an incretion. The products of some secretory glands
have been in common use in medicine for many years. Pepsin and pancreatin
may be mentioned as members of this class, the value of which is well known
and does not call for further consideration. On this occasion we are chiefly
concerned with the uses of the incretions and the conditions in which their
value has been definitely proved. As the physiological principles upon which
organofcherapeutic treatment is based have already been so clearly put before
you by Professor Swale Vincent, I shall confine my remarks to the conditions
in which such treatment is of proved value.

The thyroid gland supplies an incretion containing at least one active

Section of Therapeutics and Pharmacology

hormone, thyroxin, of which the composition is known. Fortunately the
thyroidal hormones can be absorbed unaltered in activity from the alimentary
canal, and can therefore be given by the mouth either in the raw gland or in
special preparations, such as a liquid extract or a dry powder, which can be so
conveniently dispensed as a tablet of any desired strength. The first and most
important use of these preparations is to supplement a failing thyroid gland
which, owing to fibrotic atrophy or other destructive lesion, can no longer pro¬
vide even the minimum amount of hormone necessary for the maintenance of
metabolism at the normal level. Under these circumstances the symptoms of
hypothyroidism in its lesser degrees are present, as indicated by mild cretinism
in the child and slight myxcedema in the adult, and call for early recognition.
In these cases small doses of 5 minims of liquor thyroidei or of 2 or 3 gr. of
dry thyroid each day will be followed by steady improvement and the dis¬
appearance of all symptoms due to thyroidal insufficiency. In the later stages
of thyroidal atrophy, which are accompanied by well marked cretinism in the
child or myxcedema in the adult, correspondingly larger doses produce equally
successful results, provided no incurable degenerative change in any other
organ has developed. In such cases, after removal of the symptoms, the
patient can be kept free from any signs of hypothyroidism as long as ever the
treatment is adequately maintained. When thyroid treatment is begun there
is a latent period of a week or more before any definite effect is observed.
Kendall has shown by repeated observations on the basal metabolic rate that
after a single injection of thyroxin in a case of myxoedema there is a latent
period with a slow increase of reaction which reaches a maximum at about the
tenth day and persists for five to seven weeks. Boothby has calculated that
in order to maintain a normal basal metabolic rate, 12 to 14 mgm. of active
thyroxin must be present in the body, and that the thyroxin is used up at the
rate of about 0’5 mg. a day. In order to maintain a normal basal metabolic rate
in a fully developed case of myxcedema due to complete thyroidal atrophy it
would require a daily intravenous injection of this amount of thyroxin. A
larger amount is necessary when given by the mouth. Plummer and Boothby
estimate this at about 1*5 mg. daily. From clinical observation of cases which
have been successfully treated for many years I estimate the equivalent
amount of liquor thyroidei (B.P. 1898) to be 10 minims or 5 gr. of fresh gland,
as this is a sufficient daily dose to maintain health after complete atrophy of
the thyroid gland. In the treatment of simple parenchymatous goitre a daily
dose of 2 gr. of dry thyroid is often very useful. If any symptoms of hyper¬
thyroidism are present its use is, of course, contra-indicated. As the thyroidal
hormone is a powerful stimulator of metabolism, there are other conditions in
which its use is beneficial. In diseases of the skin, and specially in the treat¬
ment of psoriasis, remarkable effects may be obtained, as has been shown by
Dr. Bramwell. Dry thyroid is also of considerable value in the treatment of
chilblains, especially if calcium is given at the same time. In simple obesity
thyroid is seldom beneficial unless it is combined with a suitable diet, and it
must be used with caution, or harm may be done if large doses are given. In
some menstrual disorders, and in nocturnal enuresis, Dr. Leonard Williams
has shown the beneficial action of quite small doses.

In tertiary syphilis good results have been obtained, due probably in part
to the iodine contained in thyroxin. The stimulation of metabolism at the
same time probably aids the action of the iodine on some resistant lesions,
especially when the skin is involved. We know very little about the relation¬
ship of the thyroid gland to the alimentary canal. Constipation is usual in

Murray: Present Position of Organotherapy

myxoedema, while frequency of defaecation is common in Graves’ disease, so
that the thyroidal hormones are evidently stimulators of intestinal peristalsis
and relieve some forms of constipation. I may briefly mention a recent case
which suggests that possibly thyroid treatment has other uses in the treatment
of diseases of the alimentary canal.

On August 11 a woman, aged 48, was admitted to my ward at the Manchester
Royal Infirmary and gave a history of recurring attacks, at intervals of several years,
of gastric pain and htemafcemesis from the age of 18. As a result of two separate
X-ray examinations it was reported on September 1 that “ there is an irregularity of
outline associated with an hour-glass condition of the stomach and the five-hour meal
showed considerable delay in emptying. The X-ray examination suggests an ulcer
fairly high up on the posterior wall.” Operation was advised by a surgical colleague
but as the patient had signs of early myxoedema it was decided to treat this condition
first. As the symptoms of myxoedema disappeared the gastric symptoms also subsided
and the X-ray report of October 17 was as follows: “ Stomach outline quite regular.
Duodenal cap well formed. Nothing abnormal seen in duodenum. No delay in
emptying.” So no operation has been performed.

Parathyroid Glands .

For many years the function of the parathyroid glands has been under
discussion; some have held them to be of great, others of little importance.
There seems, however, to be good reason for the view that they neutralize or
prevent the formation of guanidine, excess of which is probably a cause of
tetany. These glands are also concerned with the regulation of calcium
metabolism. Dr. H. Vines holds that in addition to the action of parathyroid
gland substance in the relief of tetany it also stimulates a leucocytosis and is
of value in the treatment of chronic septic conditions. The best results are
obtained by a single daily dose of t«t gr. of the dried gland by mouth.

Suprarenal Glands .

We know that Addison’s disease is due to a destructive lesion of the supra¬
renal glands, and we also know that adrenalin can be extracted from the
medulla of these glands, but there is a large gap in our knowledge between
these two observations. Administration of the whole adrenal gland or of any
preparation of it is quite unable to take the place of the functionless gland. I
have never seen permanent improvement take place in a case of Addison’s
disease as the result of this treatment. A few recoveries are recorded but it is
probable that in these cases, as was found in one case, the symptoms are due
to loss of one suprarenal gland, and that recovery is due to the development of
a compensatory hypertrophy of the other. We may reasonably look forward to
a satisfactory treatment of Addison’s disease, but the right way to supplement
adrenal deficiency has not yet been found. We have, nevertheless, in adrenalin
an extremely valuable remedy the uses of which, owing to its action on the
sympathetic nervous system, are well known. I need only remind you of its
value in the treatment of shock and of its local action in arresting haemorrhage
in epistaxis and gastrostaxis. Another valuable use of adrenalin consists in
its relaxation of spasm of involuntary muscular fibres and it is now a well-
known remedy for asthma. The hypodermic injection of from 1 to 5 minims
of the official solution gives prompt relief in many cases and the continued
daily use of even large doses for several years in order to prevent the asthmatic
attack has not, to my knowledge, had any harmful effect. Dr. Brian Melland
informs me that in one of his patients almost daily doses of as rnuchas I 5

Section of Therapeutics and Pharmacology

minims of adrenalin solution have been used for more than fifteen years for the
control of asthma and that the blood-pressure in this case is lower than it was
formerly. The use of adrenalin in the treatment of oesophageal spasm, as first
suggested to me by Professor J. N. Langley, has had a remarkable effect when
swallowed by patients in 15-minim doses ten minutes before meals in the few
cases in which I have employed it [3], Dr. Ashby informs me that he has
had excellent results in the treatment of this condition in young children by
adrenalin.

Pituitary Gland .

What has already been said with regard to the suprarenal glands applies
largely to thepituitary gland. Assuming that adiposo-genital dystrophy is due
to loss of pituitary hormones we are unable to replace them by glandular
preparations given by mouth, or to remove the signs of this disorder by this
means. Pituitrin is a valuable remedy when given subcutaneously as a
stimulant of involuntary muscular contraction. It has a well recognized place
as a uterine stimulant in obstetric practice but should only be used under well-
defined circumstances, or disastrous results may follow. Dr. Dale [4] has
shown that there is an enormous difference in the strength of different
preparations of pituitrin and this may account for the rupture of the uterus
which has been known to occur after its use. It has proved useful in the
treatment of paralytic distension of the bowel, provided there is no mechanical
obstruction. As a temporary cardiac stimulant in acute disease, such as
pneumonia, pituitrin in my experience has been of use when strychnine and
camphor have failed.

Gonads .

There is very little satisfactory evidence to show that either testicular or
ovarian preparations have any therapeutic action when injected or taken by
the mouth. The development of eunuchism after removal of the testicles and
the corresponding condition after removal of the ovaries are generally considered
to be due to loss of internal secretion of the gonads. There is, however, no
clear evidence that either eunuchism can be removed by the use of testicular
extract or the signs of a premature post-operative menopause averted by taking
ovarian tablets. The relief of subjective sensations has been reported, but this
is not sufficient evidence. We still have to learn how to administer the internal
secretions of the gonads in an effective form, if we are to succeed in making a
eunuch, for example, grow a normal amount of hair on the face. An active
preparation of the pancreatic incretion has long been sought and the recent
achievement of Banting and Best in obtaining in insulin an efficient extract of
the islands of Langerhans encourages us to hope that further researches may
yield new and useful therapeutic agents from the endocrine glands and teach us
how best to employ those we already possess.

In summarizing the present position of organotherapy we may certainly
claim that in preparations of the thyroid, parathyroid, pancreas, suprarenal and
pituitary glands we possess agents of proved value. In the case of the other
endocrine glands while recognizing the importance of their functions we cannot
fairly claim that we know as yet how to obtain or employ active preparations
made from them. To those of us who have devoted attention to endocrinology for
many years the recent exploitation of organotherapy for all kinds of diseases is
deplorable, as it is apt to discredit what is a valuable means of treatment when
properly employed.

REFERENCES.

1 Collected Papers of the Mayo Clinic, 19*21, xiii, p. 1K4. ’2] Prcsrriber , October, 1922,

p. .3 Brit. Med. Jouni ., November 27, 1920. f4j Medical Research Council, Special Report

Series, No. G9.

Grove: Present Position of Organotherapy

Dr. W. R. Grove.

My remarks deal mainly with the clinical aspect of parathyroid treatment.
It was through investigations of calcium metabolism in the blood that my
introduction to the use of parathyroid took place, and therefore I must extend
my record some years back. In the British Medical Journal of 1906, 1 Stephens
first drew attention to the good effect of calcium salts, chloride and iodide, in
ulcers and other diseases ; this at least was my first introduction to the use
of calcium salts. I was able to confirm his good results in the treatment of
ulcers and, in addition, of many catarrhal conditions of the mucous membranes,
bronchial and intestinal, and some kinds of eczema, all of which seemed to
benefit equally from the administration of these salts. Moreover, for many
years, acting on the suggestion of Dr. Dixon, of the Pharmacological Laboratory
at Cambridge, I had been injecting intramuscularly calcium chloride in 1 gr.
doses, diluted 1 in 100, in the treatment of haemorrhages which could not be
reached surgically. Here again the results were more than satisfactory, but
they were purely clinical. I could not find what happened in the blood as the
result of such injections, and therefore it was impossible to say when an
injection could be safely repeated. On the other hand Dr. Dixon told me that
however good the results might be from calcium salts taken by the mouth,
they were certainly not due to the absorption of these salts into the blood, for
the total amount could be recovered from the faeces; but he would not say
they were not absorbed into the blood from the stomach and secreted again
into the large intestine and thus in passing through the blood some result
might be obtained.

So that two and a half years ago my position was this, that I was a
thorough believer on clinical grounds in the effect of the administration of
calcium salts both by the mouth and by intramuscular injection, on certain
morbid conditions of the body, especially in aiding healing and the natural
repair of tissue ; but I was completely in the dark as to what was happening.
It was then that Dr. Vines, who knew of my interest in calcium and had
perfected his method of estimating blood calcium, asked me to collaborate with
him from the clinical side of the work.

The first case taken was that of a prematurely old woman, aged 55, with a
large and long-standing varicose ulcer, completely encircling the leg. She was
taken into hospital and kept in bed. She was found to be very deficient in
calcium ; there was very little more than 40 per cent, of normal. Intra¬
muscular injections of calcium chloride were given at weekly intervals and the
calcium content of the blood was increased, but never more than to 80 per cent,
of normal; this was always varying and, generally, it could be said that the
higher the calcium content of the blood, the greater the improvement in
the ulcer. Injections were stopped for three weeks and calcium chloride was
given by the mouth ; the blood calcium then ran at a lower level and the ulcer
increased in size. By this time some half-dozen other cases were also under
the same treatment; they all showed a calcium deficiency, improved by intra¬
muscular injections, though never completely reaching normal; all showed
improvement in the condition of the ulcers with the higher content of the
blood calcium, while calcium administered by the mouth showed no improve¬
ment in the blood and little in the ulcer. We were therefore in the position of
being sure that calcium was a factor in healthy healing ; as Dr. Dixon had

i Brit. Med. Journ 18%, ii, p. 138.

Section of Therapeutics and Pharmacology

predicted, little good was done by oral administration, but more by injection
into the muscles.

After two hundred days of these experiments, during which time half-a-
dozen cases had shown the same reactions, we had not been able to establish
the state of normal calcium in the blood. It was then that we began giving
parathyroid gland in gr. doses daily. In every case the blood rapidly
became normal, never taking more than a fortnight to become so ; and the
ulcers began to heal rapidly. At the end of five weeks from the time of
beginning parathyroid treatment, the first and largest ulcer which had com¬
pletely encircled the leg, and which had gone on with varying results for some
two hundred days before commencing this treatment, was completely healed.
In the case of the smaller ulcers this result came much more rapidly.

We had therefore reached the point of being able to say, in the case
of lesions which could be watched, that calcium was an important factor in
their healing, that deficient calcium was combined with non-healing, that para¬
thyroid was capable of influencing calcium metabolism, reducing a deficiency
in it to normal, and with normal calcium healing speedily occurred.

After this ocular demonstration we then tested the blood in many other
diseases in which the lesion is not apparent; and naturally among the first
were gastric and duodenal ulcers. In all of these the blood calcium was
deficient and the administration of parathyroid produced beneficial results in
clinical symptoms, though the blood did not always very quickly become
normal, and even when it had reached that point or near it, relapses in the
content were not uncommon. At the time we believed this to be due to an
increased absorption from the ulcer itself, neutralizing the stimulating effect
of the parathyroid. Moreover, in some cases after stopping parathyroid
administration definite clinical relapses occurred. Then we had some trouble
with new cases of varicose ulcer: the previous series had been old chronic
cases, usually without pain, and these had speedily healed up, but in the new
cases the ulcers were small, just beginning, very painful, and refusing to heal.
After the experience of the first series these results were disappointing, and the
advisability of a search for a previous focus of sepsis occurred to me. In every
case this focus was easily found, most often in pyorrhoea; and after the
offending teeth had been removed, the parathyroid acted at once. Further,
the old series of varicose ulcers was again examined, and in every case some
other focus of sepsis was found. It therefore seemed that ulceration only
occurred in varicose veins when the body resistance to a septic focus had
broken down.

There is no doubt that gastric and duodenal ulcers arise from a similar
cause, and if the original septic focus can be found and cured parathyroid will
aid in the rapid healing of the ulcer. Several undoubted cases of long standing
treated on these lines have remained free from dyspeptic symptoms under
ordinary diet longer than ever before, and the patients are satisfied they
are cured.

Connected with these cases an acute phlebitis with oral sepsis was also
found to be calcium deficient. Under parathyroid treatment the pain and
swelling rapidly disappeared, the teeth were extracted, and now a year
afterwards the man says his veins have never given so little trouble. Bedsores
and severe burns have likewise been assisted to heal by parathyroid, and in
the case of burns the calcium deficiency may help to explain the complication
of duodenal ulceration.

The question as to whether a calcium deficiency may be considered as an

Grove: Present Position of Organotherapy

index of the absorption of a toxin received confirmation in the experimental
injection of the prophylactic vaccine against influenza into myself on two
occasions. In both instances my calcium content was normal before injection;
in twelve hours the deficiency was at its maximum, and in the first instance
had not returned to normal in thirty-six hours, but in the second (three
weeks afterwards) it was normal this time.

With these results it is not surprising that all diseases of the rheumatic
group showed invariable calcium deficiency—rheumatoid arthritis, osteo¬
arthritis, chronic rheumatism, sciatica. And in every case there were undoubted
symptoms of improvement after the administration of parathyroid. In a case
of true osteo-arthritis with ankylosed joints there was only lessened pain :
but in rheumatoid arthritis there has generally been a cure, especially
where the septic focus could be found and satisfactorily treated. But even if
the original sepsis cannot be cured a favourable result is not impossible.

A case of mon-articular rheumatism in an old lady, following an acute
cholecystitis, is practically the only failure. Here the blood was very resistant
to parathyroid, taking some six weeks to reach the normal, and, practically, she
never experienced any good effects, except that she thought she slept better.
The sepsis under tension was apparently too much for the remedy.

In cases of sciatica there was found an invariable calcium deficiency, and
the administration of parathyroid gave speedy relief to the pain, so that the
patients were in a few days able to see the dentist they had neglected.

In all these usually disappointing diseases of this group, in spite of the
absolute failure mentioned, I am convinced no other ordinary treatment is
as satisfactory.

In acute rheumatism calcium deficiency was found, and was watched under
salicylates; as improvement sets in the calcium content improves and a
relapse was not foretold by further deficiency, but seemed to be contem¬
poraneous. If a bruit developed parathyroid was given, and in all cases
disappeared eventually. Whether parathyroid was a factor in that recovery I
cannot say, but on general principles it is well worth a trial in such cases.
Pericarditis has also shown an early improvement under parathyroid exhibition.

It is one of our regrets that during these investigations we have not been
able to find a case of malignant endocarditis; in this disease it is certain that
calcium deficiency will be found, and the blood should be examined once a week
to see if reaction is possible.

Other acute diseases—diphtheria, scarlet fever and influenza all showed
calcium deficiency, and it is probable that complications following these are due
to the natural reaction being unable to overcome the prolonged action of the
toxin, and possibly parathyroid may aid this reaction.

Of nasal infections, unrelieved by operation or when it has been refused,
there are no cures to be recorded, yet the relief has been greater than that given
by any other treatment, and as long as parathyroid is continued the patients
are comfortable and both look and are in better health than they have been for
years.

A gumma of the face gave a remarkable reaction to parathyroid. For
months it had been very resistant to antisyphilitic remedies, and when para¬
thyroid administration was begun the patient was in her third series of
arsenical injections. These were stopped and the blood was deficient in
calcium. In a week under parathyroid, the calcium content was normal and
in twelve days the ulcer, from being the size of a florin, was completely healed,
and after fourteen months it remains so.

Section of Therapeutics and Pharmacology

Another striking success was a case of herpes zoster of the conjunctiva
with iritis. The patient, a man aged 60, had been under treatment for four
months, six weeks in the London Hospital. It was still unhealed, and his
vision was only perception of light. He was calcium deficient. Within a few
days of beginning parathyroid treatment the chemosis improved, the power of
vision increasing almost daily, so that in a month he could read print
fairly well. A similar case was that of a patient with hypopyon following
trauma, which completely absorbed under parathyroid administration after
removal of septic teeth. In a case of delayed healing of fracture, also with
calcium deficiency due to a very bad state of the teeth, the patient refused dental
treatment, but under parathyroid the deficiency improved and the fracture
healed. A child suffering from a very chronic otitis media was also calcium
deficient, and under parathyroid the discharge first increased and then slowly
diminished.

In the treatment of pernicious anaemia there is a hopeful field ; two cases are
now under observation; there is calcium deficiency yet improvement is obvious,
it is too early in such a disease to make any definite prognosis.

In cases of ulcerating and inoperable carcinomata, calcium deficiency has
been found, but under parathyroid treatment the blood has improved or
become normal with simultaneously a great decrease in pain, so that morphia
could be almost stopped. In the case of cancer of the stomach there was less
vomiting and in one case there was an increase of weight for some weeks, with
a complete abatement of symptoms and a feeling of perfect health.

All of these cases are clearly septic diseases, but enlargement of the
prostate has never, I believe, been attributed to sepsis ; yet about a dozen
cases have shown calcium deficiency and have been treated with parathyroid
and many more have received the treatment without blood examination with
striking results.

J. C., aged 81, was first catheterized on August 8, 1921 : he had much haemor¬
rhage ; he was sent into hospital and refused operation. He did not regain power, and
was sent out with a catheter and was seen on October 6 quite unable to pass anything
without his catheter. He was calcium deficient, and was put on parathyroid treatment,
and bv October 18 his serum was normal and two or three days previously he had
passed a little urine spontaneously. By November 5 he was passing more and more
spontaneously, he thought about a pint a day, but he still used the catheter twice
daily. On December 15, two months from the commencement of treatment, he left off
using the catheter for good. He is now a healthy old man with a good complexion,
disturbed only once or twice at night; he takes parathyroid at intervals, and has kept
well up to date, though he steadily refuses to part with three septic teeth.

In our earlier papers [2] Dr. Vines and I described cases of tachycardia,
chronic tonsillitis, neurasthenia, arteriosclerosis with and without anginal
attacks, high blood-pressure, and certain cases of menorrhagia, in all of which
there was calcium deficiency, and all showed definite improvement with
parathyroid.

Dosage .—To standardize results the same preparation of parathyroid has
been used throughout. Of the preparations on the market as estimated by Dr.
Vines, all are not equally potent, one in fact was practically inert. The dose
given has been one tablet of x^ gr. daily, and in cases in which the blood has
been slow in returning to the normal state, one twice a day has not hastened
matters. In view of the threatened shortage of parathyroid, I am not sure that
the dose could not be lessened. No harmful nor untoward effects have been
found. One correspondent lias told me of a patient who gave them up because

Grove: Present Position of Organotherapy

they caused her headaches, but this is the only instance I have come across
in many hundreds of my patients. In the early stages of treatment certain
effects may arise in the septic focus responsible for the general condition, a
purulent discharge may increase in amount, or may appear where absent
before ; a chronic appendix may become acute, septic teeth may begin to ache
and give evidence of concealed trouble. In three cases under treatment an
attack of erythema—almost erysipelas—appeared. In all of these there was
marked dental sepsis. Apparently, at times, the defensive mechanism at the
septic focus has been physiologically stirred up.

The septic foci believed to be the cause of the calcium deficiency have in
various diseases been found in a chronic ear discharge, the tonsils, the nasal
accessory sinuses, a chronic appendicitis, the gall-bladder, probably the colon
as evidenced by colitis, possibly chronic constipation, possibly the uterus, but
most of all in the teeth. Here ulceration of the gums—pyorrhoea—has often
been the cause, since removal of the teeth has materially changed the condition
for the better. A red oedematous line leading from the gum margin to the
apex of the tooth is an infallible indication for its removal. From personal
observation in all these cases the apex of the tooth has shown erosion. In
lesser instances of pyorrhoea I have found no better local treatment than
rubbing the gums with dry salt. The pain and bleeding gradually lessen, but
it has the very real disadvantage of being too cheap and common. Generally
speaking, in an open discharge, e.g., from an ulcer or superficial pyorrhoea, or
from the ear or tonsils, the blood quickly becomes normal under parathyroid
treatment, while in a closed situation, such as the gall-bladder, an appendix,
and often nasal sinusitis, and an abscess at the root of a tooth, the blood con¬
dition improves under parathyroid, but may take weeks to become normal,
with even occasional relapses.

There is strong evidence, therefore, that calcium deficiency is an index of
the absorption of a toxin, and that many chronic diseases, some of which have
been mentioned, are due to the breakdown of the defences of the body in con¬
trolling this mechanism, which is apparently situated in the parathyroid
glands. In some diseases at least, the site of the resulting lesion depends on
the special idiosyncrasy of the individual, but it is just possible that in others
a second unknown factor may guide the toxin into its own particular channel.

Parathyroid has shown a definite remedial action in all the chronic diseases
accompanied by a calcium deficiency, which is simultaneously abolished or
brought to normal.

Yet parathyroid is not a universal “ cure-all, M in fact, with our present
knowledge, it is not a cure for any disease. On the other hand, it is a physio¬
logical aid to the healing of chronic lesions due to toxin absorption : if the
focus of this toxin be removed, parathyroid will then, and then only, bring
about a cure. If the focus cannot be removed parathyroid is but a remedial
agent, though a valuable one.

Whether complications of acute disease will also show improvement from
the administration of parathyroid is a subject for longer and more extensive
trial.

Of the older uses of parathyroid in tetany, I have no experience. I have
found it no help in paralysis agitans, but the cases were well advanced. I can
only confirm the observation that it has a controlling influence in epilepsy.

REFERENCES.

fl | Vinks, Journ. Physiol 1921, pp. lv, p. 86. [2] Grove and Vines, Brit. Med. Jo urn.,

1921, ii, pp. 11, 687 ; 1922,'i, p. 791. [8, Vines, Proc. licy. Soc. Med., 1922, xv (Sect. Therap.),

pp. 13-18.

Section of Therapeutics and Pharmacology

Dr. H. Vines

said that in. all the various diseases improved by parathyroid therapy the
underlying condition was sepsis. In some cases in which the white blood count
had been low, the full polymorphonuclear leucocyte count had risen to 18,000 in
two or three weeks. In many cases increased purulent discharge had followed
parathyroid therapy. He believed the action to be a stimulation of leucocytes,
probably indirectly through the action of calcium on blood plasma. Broadly
speaking, he believed that the use of parathyroids increased physical resist¬
ance to bacterial disease.

Professor W. E. Dixon, F.E.S.

(who was asked by the PRESIDENT to describe recent experimental evidence
of the action of ovarian extract) said that Harvey Cushing had observed that
pituitary extract was secreted into the cerebro-spinal fluid. In order to
determine whether pituitary secretion was present in the cerebro-spinal fluid,
he (Professor Dixon) had put a cannula into the spinal canal in dogs and cats
and had tested the fluid by its action on uterine muscle. He had succeeded
in finding pituitary extract present in nearly every specimen, though different
samples contained different amounts. In attempting to ascertain what
substance or substances could increase the pituitary secretion, he had found
that the one substance which invariably produced an immediate increase
in pituitary secretion was ovarian extract boiled, filtered, and injected into a
vein. The active substance was not present in the corpus luteum, nor was
orchitic extract efficacious. This stimulating action of ovarian extract
appeared to offer an explanation of the normal action of the pituitary body
on uterine muscle. It did not explain the intestinal action of pituitary
extract. However, it was found that extracts of duodenum also produced
increased pituitary secretion, though not immediately. The increase was
smaller and more prolonged. Pituitary extract increased the tone of the
whole of the small intestine, and wide relaxation of the large intestine was
associated with this, the reason being unknown.

Dr. W. Langdon Brown (President)

said that the discussion had been most interesting, none the less so because
Professor Swale Vincent had opened it with a refreshing dose of scepticism.
It was quite time that they should be reminded of the need for studying the
underlying physiological basis for all this work, and should take a little more
careful stock of the evidence for and against any particular diseases being
associated with endocrine defects and of their possibilities of remedy by
organotherapeutic means. Organotherapy was lagging some way behind
the observations made in endocrinology. It must be admitted that the basis
upon which the clinical observations had been made was in many instances
not as satisfactory as could be wished. At the same time the observations
which Dr. Grove and Dr. Vines had brought forward showed that evidence
was available by clinical means, apart from ordinary physiological laboratory
experiments, which would meet all the tests that could be asked of it. The
observations mentioned by Professor Dixon were very important as showing that
there was something in the ovary which definitely stimulated the pituitary
gland. Therefore he did not think one should take up so negative a position

24 Langdon Brown: Prese?it Position of Organotherapy

as Professor Swale Vincent had done. In the glycosuria of pregnancy the
blood-sugar curve had been demonstrated by Mackenzie Wallis to be exactly
the same type of curve as the one given in hyper-pituitarism, suggesting again
some direct influence of the gonads on the pituitary. He mentioned two
cases in which he had used ovarian extract, and in which the evidence
pointed to a definite effect.

A woman, aged 20, had an artificial climacteric induced by the removal of both
ovaries and tubes for tuberculous disease. She began to put on weight, which was not
unexpected, and she had also curious seizures, attacks of choking, with quickening of
pulse and respiration, each attack lasting about six minutes, and resembling some kind
of minor epilepsy. Her thyroid swelled up during the attack, and she passed a little
sugar after the attack. She was given ovarian extract, and whereas she had previously
had three or four attacks a week she had had only one attack since last Easter.
This patient was observed under hospital conditions ; she did not know what she was
taking, and no attempt was made to suggest that it was going to have a remarkable
action.

The other case was one of thymic asthma. A number of remedies had been tried,
and the attacks continued to be quite frequent. After ovarian extract was given they
became less frequent, and were now rare.

It would appear that here ovarian extract had some therapeutic effect,
but he (the President) himself had approached this question as a sceptic, and
he still recognized that it was necessary to look to the basis of the clinical
observations very thoroughly.

Section of Gberapentics ant> pharmacology

President—Dr. W. Langdon Brown.

DISCUSSION ON THE ACTION OF QUINIDINE IN
CASES OF CARDIAC DISEASE.

Professor Francis R. Fraser.

SEVERAL hundreds of cases have been recorded of auricular fibrillation in
which normal rhythm has been restored, and we can accept it as demonstrated
that quinidine can bring about this change of mechanism in a large proportion
of all cases. Our knowledge of the pharmacology of quinidine has been
greatly extended by the recent work of Lewis and his colleagues [l], but
our knowledge of the therapeutics is small, probably because of lack of
ability to ascertain the causes of auricular fibrillation in patients.

Like all powerful drugs quinidine can bring about effects that are un¬
pleasant or even dangerous, and so, necessarily, we should learn in what cases the
conversion can be effected without producing such results. The advantages to be
gained might conceivably be so great that the risk of unpleasant symptoms is
not a serious deterrent to giving the drug, but in digitalis we have so successful
a method of treating the effects of auricular fibrillation that we must seriously
consider in what cases a successful quinidine result surpasses the effect of
digitalis treatment in therapeutic value. To maintain the normal rhythm it
may prove in some cases to be necessary to continue the administration for a
long time or even indefinitely. This may produce greater comfort or effici¬
ency than the continuous administration of digitalis.

If quinidine treatment is to find a place in general therapeutics, answers to
the two following questions must be obtained:—

(a) In what cases can the conversion be brought about without risk of
producing dangerous symptoms ?

(b) In what cases does the therapeutic effect of this conversion surpass that
of digitalis treatment ?

A discussion here may well help us to answer two further questions:—

( c) What is the best method of administration, especially in regard to
dosage ?

(d) For how long after the conversion should the quinidine treatment be
continued ?

In this country Hay [2] advocates 2 grm. a day in ten doses of 0‘2 grm.
each, while Parkinson and Nicholl [3] and Clark-Kennedy [4] give it three
times a day or at six-hourly intervals. Similar differences in practice are
recorded in the foreign literature.

Many other questions must arise, but preliminary answers to these four are

Jv—T h 1 [March IS, 1 !V25.

Fraser: Quinidine in Cases of Cardiac Disease

desirable before the necessary amount of material will be collected on which
sound therapeutics can be based.

The effect of quinidine on disturbances of the mechanism of the heart¬
beat other than auricular fibrillation and flutter will, I have no doubt, be
referred to by other speakers, but my experience with them has been too
small to justify any reference from me. Many interesting electro-cardio-
graphic phenomena have been observed as a result of quinidine treatment, but
this is probably not a suitable occasion for their discussion in detail.

I shall first describe four cases in which the administration of quinidine
resulted in dangerous symptoms, or in symptoms so distressing that the
administration had to be stopped before any beneficial effects were
produced.

(1) Among the earlier cases in which I tried quinidine was that of a woman, aged
54, with mitral stenosis and regurgitation, who was readmitted in June, 1921, after
being under observation and treatment for a year with auricular fibrillation. When
first seen in July, 1920, she had auricular flutter, and this had changed to fibrillation
as the result of digitalis treatment. No history of rheumatic disease was obtained.
The heart was greatly enlarged both to right and left, and the apex was in the sixth
space, 5 in. from the mid-line. Under digitalis treatment she was capable of only very
light work in the house. She was put on quinidine sulphate 5 gr. at 9 a.m. and
7.30 p.m., and reverted in twenty-four hours to flutter with an auricular rate of 196.
After eight days her pulse-rate, which had continued between 80 and 90, sud¬
denly rose to 200, and the patient felt faint. Probably a 1 : 1 response
occurred. The treatment was stopped, digitalis was recommenced and fibrillation
returned.

(2) A woman, aged 31, with a history of rheumatic fever at 8 years of age and
a “ weak heart ” since, and with mitral stenosis, had auricular fibrillation wdth a
ventricular rate of only 50-65, and severe heart failure while at complete rest in bed.
Presumably some lesion of the auriculo-ventricular conducting structures was present.
On quinidine sulphate, 5 gr. three times a day, flutter resulted after five days, with an
auricular rate of 186 and a ventricular rate of 93. The dose was raised to 7i gr. three
times a day, and six days later, when the auricular rate w r as 225, with a response of
2 : 1 and 4 : 1, a Stokes-Adams attack occurred. The patient was being electro-
cardiographed at the time, and a tracing was obtained showing a ventricular stand¬
still while the auricular activity continued. Auricular fibrillation returned on stopping
the quinidine, and the patient died a year later with malignant endocarditis and tricuspid
and mitral stenosis.

(3) A woman, aged 58, with mitral regurgitation and auricular fibrillation, probably
of eighteen months’ duration, had no history of rheumatism, and had evidence of
arterial and renal disease. She had a ventricular rate on admission of 180, and the
heart was enlarged to the right and left, with the apex in the fifth space in. from
the mid-line. The response to digitalis treatment was good, but at a ventricular rate
of 90 numerous premature beats occurred. After four doses of 15 gr. of quinidine
sulphate at six-hourly intervals, normal mechanism was restored, but the patient
experienced much precordial discomfort and nausea. The quinidine w r as stopped,
and fibrillation returned a day later with relief from the subjective distress.

After the experience of these cases, I selected with care, avoiding all cases
with evidence of much damage to cardiac structures, such as great enlarge¬
ment, heart block, or severe valvular disease. Similar conclusions have
already been recorded in the literatuie.

(4) Recently I met w r ith another limitation to the administration. A woman, aged 48,
with mitral stenosis, had auricular fibrillation, possibly of only a few’ weeks’ duration.
It was this short duration that induced me to try it in a case that seemed otherwise
unsuitable. No causal infection could be determined. On admission she had severe

Section of Therapeutics and Pharmacology

abdominal pain with dyspniea, and orthopncea, and numerous r&les at the bases of the
lungs. The apex beat was in the fifth space 5£ in. from the mid-line. The response to
digitalis was good. Quinidine sulphate 5 gr. three times a day had no effect, and after
four days it was raised to 71 gr. three times a day. On this dose the ventricular rate
rose steadily, and on the fifth day, after 175 gr. in all, she complained of headache,
vomited, and the temperature rose to 100° F. Next day there was a rash on the
abdomen, lower chest, above the back of the elbows, and above the knees on the
anterior aspect of the thighs. It consisted of small rose-red papules, raised in the
centre and fading into the surrounding skin at the margins. They varied in size from
one-twentieth to one-fifth of an inch in diameter, and were in places confluent. Next
day the eruption had a morbilliform appearance, and had spread to the back in the
lumbar region, on to the upper chest, neck and lower part of face. The arms were
affected more on the extensor than on the flexor surfaces. It did not spread below the
knees or on to the hands. A few of the lesions were purpuric. The quinidine was
stopped on the first appearance of the rash, which commenced to fade on the third day,
but did not entirely disappear till the seventh day.

In the following cases there was little evidence of extensive permanent
changes in the cardiac structures and the conversion to normal rhythm
resulted without any discomfort to the patient.

(5) A man, aged 39, was admitted in July, 1921, with auricular fibrillation of
probably five months’ duration. He had syphilitic aortitis. No valvular lesion was
discoverable, but the apex beat was in the sixth space in. from the mid-line. Three
months previously when first seen he had severe heart failure at rest in bed, but he had
responded well to digitalis and had been put on antisyphilitic treatment. The Wasser-
mann reaction became negative, but he had much precordial distress and palpitations,
and there were numerous ventricular extrasystoles. Quinidine sulphate 5 gr. three
times a day w r as increased to 10 gr. three times a day after six days, and four days later,
after 180 gr., normal rhythm was restored. Three days later the dosage was reduced
to 5 gr. three times a day, and this was continued for three months while he was
attending as an out-patient. A year and a half later the rhythm is still normal, and he
states that he feels fit to return to his work as a stevedore. There are still occasional
ventricular extrasystoles.

I would suggest that in this case the treatment of the cause of t.he heart
disease was an important factor in the success.

(6) A man, aged 26, was admitted in July, 1921, with dyspnoea, oedema and auricular
fibrillation which had probably been present for six weeks only. No clear evidence of
valvular disease was obtained and no evidence of any infection other than malaria five
years before with recurrent attacks up to three months before admission. He
responded well to digitalis and there was but little enlargement of the heart. Quinidine
sulphate 5 gr. three tunes a day was increased to 10 gr. three times a day after twenty-
four hours and on the third day, after 55 gr., normal rhythm was restored. The dose
was reduced to 5 gr. three times a day two days later, and this was continued for ten
days more. The normal rhythm has continued ever since, and he is now working as a
labourer, but has occasional precordial distress.

In this case it appears probable that the cause of the auricular fibrillation,
whatever it was, had ceased to be active when the patient came under
observation.

The auricular fibrillation associated with exophthalmic goitre or other
thyro-toxic conditions is of peculiar interest, since the thyro-toxic condition
can be treated, and the next three cases are examples of the action of quinidine
in different stages of thyro-toxic activity.

17) A man, aged 40, with exophthalmic goitre had had auricular fibrillation pro¬
bably for five years. A partial thyroidectomy was performed in October. 1920, in

28 Fraser: Quinidine in Cases of Cardiac Disease

Australia without relief and the signs of heart failure were pronounced unless the
patient remained at complete rest in bed. He responded well to digitalis at the
National Heart Hospital under the care of Dr. Strickland Goodall. A further thyroid*
ectomy was performed by Mr. T. P. Dunhill, in October, 1922, at St. Bartholomew's
Hospital, with great improvement in the thyro-toxic symptoms, but the auricular
fibrillation was still present three weeks later. He was put on quinidine sulphate 5 gr.
three times a day, and after four doses the rhythm became normal. There was no
evidence of valvular disease, and the apex beat was in the fourth space 4^ in. from the
mid-line. The quinidine was continued in diminishing dosage for a further ten days.
The rhythm is still normal and the patient is steadily increasing his activities.

The removal of the toxic thyroid gland probably removed the cause of the
fibrillation, and the quinidine was of value in disturbing a mechanism that
tends to be stable when once developed.

(8) A woman, aged 45, had exophthalmic goitre seven years ago. After various
medical treatments the general thyro-toxic condition gradually subsided, but without
improvement in the palpitations, oedema and shortness of breath. It is probable that
auricular fibrillation had been present for some years. On admission in July, 1922, she
had oedema of the legs, back, and bases of the lungs, and the apex beat was in the fifth
space 4£ in. from the mid-line. The response to digitalis was good and she was
discharged a month later. In October, 1922, she was readmitted to try the effect of
quinidine, and it was found that the thyro-toxic symptoms were rather more pro¬
nounced than in the summer. After six doses of quinidine sulphate 7i gr. three times
a day, the rhythm became normal. The quinidine was gradually reduced and dis¬
continued four weeks later, and when the patient was discharged the apex beat was in
the fourth space Bi in. from the mid-line. While at home she developed a bad cough
and auricular fibrillation returned. On readmission in February, 1923, a great increase
in the thyro-toxic symptoms was found to be present, and a partial thyroidectomy was
performed on February 22. As she was still fibrillating on March 1, quinidine
sulphate 5 gr. three times a day was commenced and normal rhythm restored after
four doses. She is still on quinidine, and a further thyroidectomy may be necessary
before all thyro-toxic symptoms disappear and before a stable normal rhythm is obtained.

(9) A woman, aged 46, with large multiple cysts of the thyroid gland of many
years’ duration, had severe heart failure and auricular fibrillation for four weeks. There
were thyro-toxic symptoms and the basal metabolic rate was from + 35 per cent, to -f 50
per cent. The response to digitalis was good, but the auriculo-ventricular rhythm that
resulted from quinidine was unstable, nodal rhythm, auricular extrasystoles and ventri¬
cular extrasystoles interfering with the regularity. During a bad attack of quinsy with
purpura the thyro-toxic symptoms increased and fibrillation returned in spite of the con¬
tinued quinidine administration. The quinidine was stopped, and after the subsidence of
the acute infection its administration was recommenced and normal rhythm was again
established. This persisted through the strain of tonsillectomy and the removal of all
her teeth, which were very septic, and is still present two months later. She declines
to have the thyroid gland operated upon and continues to take quinidine 5 gr. three
times a day.

These two cases suggest that so long as the cause of the auricular fibrilla¬
tion remains active, the normal rhythm resulting from quinidine treatment
will not be stable, and in the next case this suggestion is supported by the
result of treatment in a patient suffering from rheumatic infection of the
heart.

(10) A woman, aged 26, with mitral stenosis and auricular fibrillation gave a
history of rheumatic fever four years previously, and of a probable onset of the
fibrillation two months previously. There was slight (edema of the ankles, severe
dyspnoea on exertion, palpitations on exertion and frequently ako when at rest. The
apex beat w T as in the fifth space 33 in. from the mid-line. The response to digitalis

Section of Therapeutics and Pharmacology

was good. Quinidine sulphate 5 gr. three times a day caused a return to normal
rhythm after seven doses, with cessation of the palpitations and precordial distress
that had persisted on digitalis, but the dyspnoea was still severe. After thirteen days
the dose was reduced to gr. three times a day, and she was discharged on this
amount. A month later an attempt was made to relieve the dyspnoea by adding
tincture of digitalis 5 minims, and later 10 minims, three times a day, but this was
without effect on the symptoms and did not disturb the rhythm. Three months after
leaving hospital she had a bad cold and fibrillation returned for a few' days, and a
month later pains in the knees, pains over the precordium and attacks of palpitation
occurred with a return of auricular fibrillation. The quinidine was stopped and sodium
salicylate and digitalis were commenced. When the attack, probably one of rheumatic
infection, had subsided, quinidine again restored normal rhythm. During the last nine
months she has continued to take quinidine 5 gr. three times a day, but has fibrillated
for a few days on three definite occasions. On one of these she had much worry in
connexion with the death of her mother, on another she had tried to do some heavy
work, and on the third she had a bad cold.

It seems probable that the rheumatic infection is continuously or inter¬
mittently active and that the quinidine is just sufficient to prevent fibrillation
except during a relapse, when another infection is present, when worry or
mental strain occur, or with physical strain. It is difficult to decide that she
has a raised efficiency when the rhythm is normal, but she is certainly far
more comfortable and contented.

I have seen one case of thyro-toxic auricular fibrillation in which normal
rhythm was restored a few days after partial thyroidectomy, without other
interference, and have heard of several others; and I have seen cases in which
auricular fibrillation occurred only for a few hours after thyroidectomy during
the stage when excessive excitement is seen. These cases suggest that the
auricular fibrillation is due to an active toxic action, and that normal rhythm
may result simply from the cessation of this toxic action. The difficulty in
obtaining a stable normal rhythm with quinidine in active toxic cases, and the
stability obtained after partial thyroidectomy, indicate clearly that in this type
of case in order to obtain a stable normal rhythm the thyro-toxic factor
must be treated.

In the other types of cases the indications of a similar active agent are not
so complete, but the accumulation of more evidence might well decide in favour
of a similar state of affairs in them also. The stability of the syphilitic case in
which anti-syphilitic treatment was given supports this view. The stability
in the case in which no definite valvular lesion could be found, and in which
the only known infection was malaria, may well be due to the cessation of the
causal factor, whatever it was, before the patient came under observation.

The instability of the rheumatic case when quinidine treatment was
continued for nine months is suggestive of a constantly or intermittently
active factor tending to produce fibrillation. This idea is fully in keeping with
the theory derived from the clinical study of these cases, that the rheumatic
infection continues for years, causing gradually increasing stenosis of the
mitral valve and death, often without well defined attacks of acute rheumatic
infection. In this case it is of interest to note the additional factors present
during the relapses into auricular fibrillation, namely worry and mental strain,
physical strain, and infection of the upper respiratory tract. Unfortunately
we have no successful method of treating the rheumatic infection of the heart.

In addition to active agents, toxic and infectious, it is probable that
auricular fibrillation can result from permanent structural changes in the
heart, in which case a stable normal rhythm after cessation of the quinidine
treatment would be unlikely.

80 Drury : Quinidine in Cases of Cardiac Disease

I would, therefore, conclude that:—

(1) Quinidine treatment will result in a stable normal rhythm if the cause
of the auricular fibrillation can be successfully treated or has ceased to be
active.

(2) Cases in which there are extensive structural changes in the heart,
as evidenced by heart block, severe valvular disease or great enlargement, are
not suitable for quinidine treatment, especially if the response to digitalis is
not good. In such cases unpleasant and even dangerous disturbances may
result.

(3) In some cases at least, the comfort and efficiency of the patient are
greater when a normal rhythm results from quinidine treatment, than when
digitalis treatment alone is used.

(4) In the cases in which the results are satisfactory larger doses than
10 gr. of quinidine sulphate at intervals of six hours are not necessary, nor
smaller initial doses than 5 gr. three times a day.

(5) If necessary to maintain norma! rhythm quinidine may be continued
to be administered indefinitely, and it is probably advisable in all cases to
continue it for some weeks after normal rhythm has resulted, though in
gradually decreasing doses.

REFERENCES.

lj Lewis, Diiury, Wedd and Iliescu, Heart , 1921-22, ix, pp. 207-267. [2] Hay, John,

Quart . Joum . of Med ., July, 1922, p. 318. [3] Parkinson, John, and Nicholl, J. W. McK.,

Lancet , 1922, ii, p. 1267. r 4 I Clark-Kennedy, A. E., Quart. Journ . of Med ., July, 1922, p. 279.

Dr. A. N. Drury.

Professor Fraser has brought out very many clinical points with regard to
the treatment of auricular disease with quinidine. I think that the purpose
of this discussion will be better fulfilled if I leave this aspect alone, and speak
only of the toxicology of the drug, and outline especially the effect upon the
cardiac musculature.

Before entering upon this, I must mention in passing certain symptoms,
not peculiar to patients who have cardiac disease, but common to all who are
under quinidine therapy.

The first is the sudden collapse, with unconsciousness and failure of
respiration, which occurs after a small amount of the drug has been taken.
This idiosyncrasy, which is very alarming, is fortunately not common and is
tested by giving a small dose of the drug before treatment. The unpleasant
symptoms of quinidine poisoning, such as headache, nausea, diarrhoea, and
vomiting, which also occur, are not unduly common during quinidine
administration, but must be expected to appear in certain cases ; the possibility
of their occurrence must always be borne in mind.

With regard to the effects which are produced in the cardiac musculature
when quinidine is administered. The information, which has been obtained by
experiments upon animals, where doses comparable to those employed clinically
have been used, has been fully borne out by clinical findings ; and it can be safely
assumed that similar changes are produced in the human cardiac musculature.
A study of these changes enables us to understand more clearly the cause of
the restoration of the normal rhythm and of its failure; the untoward events
which occur during quinidine administration and how to guard against poisoning
the heart to a dangerous degree. In short, quinidine lengthens the refractory

Section of Therapeutics and Pharmacology

period, and slows the conduction of the excitation wave from point to point in
the muscle. These effects are witnessed in both auricular and ventricular
muscle, and occur also in the auriculo-ventricular node and bundle ; it also
paralyses the vagus nerve to a certain degree. There is now ample proof,
1 think, that in both the conditions of auricular fibrillation and flutter, there is
a continuously circulating wave present in the auricle. In flutter the wave
follows a regular course; in fibrillation an irregular one. Now the maintenance
of this circulating wave is dependent upon the balance of three factors. The
length of the path taken by the circulating wave, the time taken for the muscle
to become responsive after it has contracted—the refractory period; and the
speed at which the wave travels from point to point—the conduction rate.
Now the important part of such a circulating movement is the gap which
exists between the head of the oncoming wave and the wake of the receding
wave. A gap of some degree is essential, if the wave is to maintain its
movement. If the gap can, by any means, be closed up, the on-coming wave
will find refractory tissue ahead of it and must die out. The three events, any
one of which may close this gap, are a shortening of the path, a quicker rate of
conduction, or an increase in the duration of the refractory period. The first
event need not be considered, as the original path is always open. Quickening
of the rate of conduction does not occur under quinidine but the reverse
happens. The refractory period, however, is lengthened, and this would
adequately explain why the circus movement is stopped, for the oncoming
wave finds refractory tissue ahead of it, the gap is closed. But quinidine
does not always stop this circus movement and this is anticipated when
it is appreciated that the conduction rate is being simultaneously slowed ;
lengthening of the refractory period closes the gap, the slowed conduction
opens it. It is only when the first factor exceeds the second that the gap will
be closed. There is also another reason why the circulating wave should not
always cease. Closure of the original gap may cause the circulating movement
to select a longer path ; a further increase in refractory period may now prove
effective or not, it depends upon the largest available path. We can now
anticipate the events likely to occur in the auricle during the treatment of
fibrillation or flutter. Partly on account of slowed conduction, and partly
on account of the closure of the gap forcing the movement on to a longer
path, the auricular movements will become slower and in one case there will
be an abrupt termination of the disorder, in another a progressive slowing of
auricular movement only. This slowing of auricular movement plays an
important part in the production of the palpitation which is seen usually
at the commencement of treatment, and occasionally subsequently. If an
auricular rate of beating is above 200 per minute, any increase in its rate is
accompanied by a slower ventricular rate. This is exemplified in the two
conditions, flutter and fibrillation. All other things being equal, the ventricular
rate associated with the former, where the auricular movement is 300 per minute,
is higher than the latter where the movement is about 450 per minute. For
this reason alone if the auricular movements of auricular fibrillation which
range around 450 per minute are slowed, the ventricular rate of beating will
rise, and if the rate of movement is forced to about 200 or lower there is danger
that the ventricle may suddenly respond at the same rate. The partial
paralysis of the vagi will also diminish any degree of block which existed
between auricle and ventricle in respect of vagal tone and allow a higher
ventricular rate. On the other hand, there is a direct action of the drug upon
the conducting tissue, for in many cases which are restored to normal rhythm

32 Clark-Kennedy: Quinidine in Cases of Cardiac Disease

the P-R interval is longer for the first twenty-four hours, and generally returns
to a normal figure when the drug has been completely excreted ; and this will
help to maintain a low ventricular rate by increasing the block between auricle
and ventricle. It would appear that the slowing of auricular movement is a
very early event, for on the first two days high ventricular rates are common:
later the conduction between auricle and ventricle is depressed, and the
remainder of the treatment is often not interrupted by such high rates,
except in those cases where a very low auricular rate of 200 brings out a full
ventricular response. These attacks of palpitation are usually not sufficient
to hinder the treatment, but may, on occasions, force a case which is on the
borderline into failure. They can be combated by giving a preliminary course
of digitalis with the idea of interposing a block between auricle and ventricle.

There is also another type of palpitation the recognition of which is
important. Studied electro-cardiographically, it commences as an occasional
ventricular extrasystole interposed between normal ventricular complexes.
There may be coupling, as is seen in digitalis poisoning; later, the extra¬
systoles occur in pairs, or short runs, and finally a run of ventricular
tachycardia about 160 per minute may occur and last for minutes or hours.
The appearance of such a tachycardia warns us that a degree of poisoning is
present which is dangerous; such tachycardias arise easily in ventricular
muscle when there is a lengthened refractory period and a slowed conduction
rate, and are always associated with low rates of auricular movement, about
250-300 per minute. They are the precursors of ventricular fibrillation and
are an indication for withdrawal of the drug. As I have outlined above,
quinidine exerts a profound effect upon the cardiac musculature, and it is
apparent that it is not a drug to be used haphazard and without thought.
Where it is used the conditions should be strictly controlled. It is, at the
moment, a treatment for the wards rather than for the out-patient department.
But, as one thinks of the patients who have gained, according to their own
evidence, a new lease of life, owing to the treatment, one does not feel that it
is justified to withhold the treatment because of its limitations, disadvantages
and dangers. Judged by results it is seen to be eminently suitable for certain
cases, and the success of the drug will be in the selection of the suitable cases;
and understanding of the effects which are produced in the musculature of the
heart during the administration must help greatly in the correct selection
of those cases.

Dr. A. E. Clark-Kennedy . 1

(I) Introduction .

In the large majority of cases, the onset of auricular fibrillation is associated
with a sudden increase in the signs and symptoms of cardiac decompensation.
It is, therefore, generally accepted that this condition is one of the factors in
the pathogenesis of heart failure.

We now have two methods of treating auricular fibrillation. By giving
digitalis the conductivity of the auriculo-ventricular bundle can be depressed.
The ventricular rate is thereby artificially controlled, but the auricles are left
to fibrillate. Or, by giving quinidine, in the majority of cases, normal rhythm
can be restored. On theoretical grounds alone, the restoration of sino-

• A more detailed account of the observations on which this contribution to the Discussion is
ha-oil i< published in the (Jmtrlt rl;/ Journal of Medicine, April, 1923, p. 20-1.

Section of Therapeutics and Pharmacology

auricular rhythm with quinidine should be a more successful therapeutic
procedure than the artificial control of ventricular rate with digitalis.

Commencing in August, 1921,1 have now investigated the action of quini¬
dine in forty-five cases of auricular fibrillation. In thirty-seven (82 per cent.)
I have seen normal rhythm restored. In twenty-nine of these normal rhythm
persisted after the patient was discharged from hospital, but in eight relapse
occurred within a few days.

An arbitrary age limit of 65 has been adopted and patients in whom oedema
persisted in spite of prolonged digitalis treatment have not been treated with
quinidine. Apart from these considerations no selection of cases whatever has
been exercised. All cases admitted in rotation to the Wards of the Medical
Unit at the London Hospital, and to a London Poor Law infirmary, have been
treated with quinidine. A thorough initial course of digitalis was administered
to all these. This was then discontinued and quinidine given on an arbitrary
but standard system of dosage: 5 gr. six-hourly was given for three days, and
then the dosage of the drug increased 4 gr. per diem, i.e., the patients received
6 gr. six-hourly on the fourth day, 7 gr. six-hourly on the fifth day and so on.
When normal rhythm had been restored the dosage was gradually decreased
to 5 gr. twice daily, which was then continued indefinitely as a prophylactic
against relapse. In all cases quinidine was pushed until symptoms of failure
or severe toxic symptoms supervened.

The maximum amount of quinidine which was found necessary to effect
the restoration of normal rhythm was 392 gr. with a maximum dosage of
15 gr. six-hourly. In another case a similar amount failed to produce a
successful result. But the majority of cases which have reacted to quinidine
have reacted to small doses, and in practice it will probably be advisable to
limit the maximum dosage on the standard system described to 9 gr. six-hourly
or thereabouts.

(II) The Ill-effects of Quinidine Administration.

These are numerous, and may be best classified as follows

(1) The General Symptoms of Quinidine Intoxication .—Headache, nausea,
vomiting, diarrhoea and abdominal pain have been common but frequently pass
off in the early stages without reduction in dosage of the drug. Excessive vomit¬
ing, in one instance associated with dangerous collapse, only occurred in two
cases, but in both normal rhythm was only transiently restored. A mild degree of
pyrexia coincided with the maximum of quinidine administration in teu cases.
All these patients were relatively young and nine were definitely rheumatic.
Whether this is due to a direct action of the drug on the heat-regulating
centre or to the lighting up of a low grade infection is uncertain. In one case
the patient developed glycosuria twenty-one days after quinidine had been
discontinued. Two cases developed papular scarlatiniform rashes, one urticaria,
and a third an eruption closely resembling that of measles. Visual symptoms
and attacks of faintness were fairly frequent during the maximum of quinidine
administration and were almost invariably associated with the fall in blood
pressure that the drug is known to prodtce at this stage. No retinal changes
were observed.

The large majority of patients have tolerated the prophylactic administra¬
tion of the drug over a year or more without symptoms.

(2) Embolism , consequent on the Restoration of Auricular Function. —This
occurred shortly after the restoration of normal rhythm in four cases. In one
of these the embolus was pulmonary and the patient died suddenly. Autopsy,

34 Clark-Kennedy: Quinidine in Gases of Cardiac Disease

however, showed that it had been derived from thrombosis in the iliac vein
and not from clots in the auricular appendices. In our very first case
simultaneous infarction of the lung and kidney and embolic blocking of a
popliteal artery occurred. The patient, however, recovered completely, normal
rhythm has persisted for over a year and a half and she remains practically
free from cardiac symptoms. In the other two cases the embolus was
splenic. No doubt I have been fortunate in that no case of cerebral embolism
has been seen. Excluding the fatal case, which is irrelevant to the present
discussion, the other three patients all had mitral stenosis and auricular
fibrillation of eighteen to thirty months’ duration.

It is not surprising that the auricle, when it first starts to contract after
several months of fibrillation, should expel thrombi into the pulmonary or
systemic circulations. But the incidence of embolism in the early cases of
my series was particularly high, and my more recent cases and the results
of other workers would tend to show that the risk of embolism is not as
great as Dr. Ellis and myself first supposed. Possibly indeed little greater
than under digitalis treatment alone.

(3) The Symptoms due to the Toxic Action of the Drug on the Myocardium.
—In all the unsuccessful cases, to which large doses of quinidine were
administered, symptoms of . cardiac decompensation were produced. No
fatality occurred under such circumstances, and these symptoms quickly
passed off when the drug was discontinued. In all these cases quinidine
treatment had to be abandoned on this account rather than on account of the
general toxic effects produced. The patient in one case, however, a female
with rheumatic heart disease, a large heart, mitral stenosis and chronic high
blood-pressure, received 180 gr. of quinidine with a maximum dosage of 9 gr.
six-hourly. This failed to restore normal rhythm and the drug had to be
discontinued on account of symptoms of failure. A long course of digitalis
now caused coupled ventricular beats. Digitalis was now stopped and
quinidine immediately re-administered. The patient died suddenly after the
second 5-gr. dose. Post-mortem examination failed to reveal the cause of
sudden death.

To give quinidine, immediately after digitalis had produced coupling, was
certainly a therapeutic mistake on my part. But it seems to me, that in this
case death should be attributed at least as much if not more to digitalis than
to quinidine. This is the only fatality that I have to report in my series
of forty-five cases. One other patient, however, a woman aged 45, with
pulmonary stenosis and a large heart, had a sudden syncopal attack in which
she nearly died.

The pathogenesis of death in these fatal cases has received various
explanations, hut autopsy, as might be expected—save to exclude embolism -
has yielded no information. Heart block, ventricular fibrillation, and failure
of the sino-auricular node to begin initiating stimuli, when fibrillation ceases,
have all been suggested.

(4) Symptoms of a Cerebral Nature. —I have occasionally observed these.
Three of my patients suddenly felt confused, seemed to lose themselves and
then shrieked out. One patient, according to the nurse’s account, suddenly
became unconscious, rolled her eyes and frothed at the mouth. A little later
she became extremely restless, she shrieked out wildly and morphia had to be
administered. These attacks occurred either shortly after the restoration of
normal rhythm or during the maximum of unsuccessful quinidine administra¬
tion. I am inclined to attribute them to transient interference with the blood

Section of Therapeutics and Pharmacology

supply to the brain rather than to embolism or the direct action of the drug
on the cerebrum.

Yon Frey has described the occurrence of respiratory paralysis during the
administration of quite small doses of the drug. No such case has come
under my observation.

( III) The Restoration of Normal Rhythm as a Therapeutic Procedure .

Of the cases in which normal rhythm persisted after discharge from
hospital, fourteen had received no digitalis treatment before admission. These
cases were admitted to hospital with failing compensation, but auricular
fibrillation had been of relatively short duration. In all these cases digitalis
and rest in bed at least partly restored compensation, caused oedema to dis¬
appear, and reduced the pulse-rate below 80.

All these cases, with one exception, remained as well up and about after
the restoration of normal rhythm as they had been when resting in bed with
fibrillating auricles, and the corresponding ventricular rates controlled with
digitalis.

In three out of these thirteen cases, objective signs of heart failure became
less pronounced when normal rhythm was first restored. But in the remaining
ten, although they mostly experienced relief from subjective sensations in the
chest— signs and symptoms of failure being absent before the restoration of
normal rhythm—no evidence of rise in cardiac efficiency at that time could
be adduced.

Of these thirteen patients ten have returned to work, and all with one
exception had mitral stenosis. In these ten cases it has been concluded that
cardiac efficiency had been restored to its original level before the onset of
fibrillation, because the patients’ capacity to do work without the onset
of cardiac symptoms was now the same as before the known date of onset of
fibrillation.

In the remaining three out of the thirteen cases, although compensation
has been maintained, the exercise tolerance of these individuals has not
returned to what it was before the known date of onset of fibrillation. These
three patients had no mitral stenosis. One had an adherent pericardium and
mitral incompetence, while the other two had no valvular lesions. These
cases are probably cases of active myocardial disease.

In the one exception referred to, the restoration of normal rhythm failed to
maintain compensation, and though sino-auricular rhythm persisted with a
normal pulse-rate, oedema and signs and symptoms of failure appeared.
Whether this patient would have been any better under digitalis, if fibrillation
had been allowed to persist, is doubtful. It seems more likely that active
myocardial disease was in progress.

(IV) The Relative Merits of Quinidine and Digitalis in the Treatment of

Auricular Fibrillation.

Of the cases in which normal rhythm persisted after the patient was dis¬
charged from hospital, eleven were cases of auricular fibrillation of relatively
long duration, which had received previous digitalis treatment. In this group of
patients only is it possible to compare the relative values of digitalis and
quinidine in the treatment of this condition.

Of these eleven cases, in seven the restoration of normal rhythm with
quinidine maintained a higher level of cardiac efficiency than had previously

36 Clark-Kennedy: Quinidine in Gases of Cardiac Disease

existed when the auricles were fibrillating, although the ventricular rate was
controlled with digitalis. In all these cases there was mitral stenosis, but in
all the aortic valve was intact. Of these seven cases, in five clinical improve¬
ment was striking, and the date of onset of auricular fibrillation being known
it was considered that cardiac efficiency had been restored to its original level
before the occurrence of this event. But in the other two cases, clinical
improvement was not pronounced, and although they were definitely better
than before quinidine treatment, cardiac efficiency had probably not been
restored to its original level before the onset of fibrillation.

In two out of the eleven cases the restoration of normal rhythm with
quinidine seemed to maintain about the same level of cardiac efficiency as
digitalis. One of these patients had syphilitic aortitis and aortic incompetence,
while the other had no valvular lesions. The latter patient felt as well after
discharge from hospital with fibrillation as after his discharge the second time
with normal rhythm. On the first occasion he stopped taking digitalis, and
compensation failed within two months, but since the second occasion, normal
rhythm with adequate compensation has persisted for over a year and a half,
and he has returned to the heavy work of a carman.

Two cases out of the eleven were definitely worse as the result of restoration
of normal rhythm. Signs and symptoms of failure previously absent now
appeared. Cardiac efficiency in these two patients was now at a definitely
lower level than when fibrillation was present, the ventricular rate being con¬
trolled with digitalis. In both these cases there was mitral stenosis, and both
developed tachycardia with the return of normal rhythm. The association of
simple tachycardia, mitral stenosis, and venous congestion is common. The
explanation of the tachycardia is doubtful, but it seems fairly certain that it
serves no useful purpose. When we restore normal rhythm in such cases, we
return to the unsatisfactory condition in which we have no means of controlling
the ventricular rate. In removing the embarrassing effects of disorder of
rhythm we have substituted the worse handicap of tachycardia. Unfortunately
the previous clinical histories of these two patients is not definitely known, but
it seems probable that they belong to this particular group* In both cases
quinidine was discontinued in the hope that relapse into fibrillation might
occur. This has supervened in one case, and under digitalis the symptoms of
failure have largely disappeared. In the other normal rhythm with decom¬
pensation has persisted in spite of heavy doses of digitalis.

(F) The Prognosis and Tendency to Relapse in Successful Cases .

All cases of this series, with a few exceptions, have continued to take
quinidine regularly as a prophylactic against relapse.

Of the twenty-eight successful cases, in eleven relapse occurred after normal
rhythm had persisted for periods of one year to one month. All these with one
exception took quinidine regularly.

In the remaining seventeen cases normal rhythm has persisted up to
date with a maximum duration of a year and a half. Three of these have
not troubled about taking quinidine, but the remainder have continued the
drug regularly.

Of the fifteen cases in which the patients were discharged from hospital
with normal rhythm over a year ago, in nine normal rhythm is still per¬
sisting. On the whole, although there seems to be considerable evidence to
show that discontinuing the drug frequently leads to relapse, normal rhythm
may persist for long periods in certain cases without the patient taking
quinidine.

Section of Therapeutics and Pharmacology

(VI ) The Indications for Quinidine Therapy.

Many oases of auricular fibrillation are unsuitable for quinidine treat¬
ment. The selection of cases may be considered under four headings, as
follows:—

(1) That quinidine will restore normal rhythm in 70 to 80 per cent, of
cases. A successful pharmacological action of the drug is to be expected in
patients with auricular fibrillation of recent onset, whose hearts are not con¬
siderably enlarged, and who are middle aged rather than young.

(2) That granted a successful pharmacological action of the drug, a good
therapeutic result is not necessarily to be anticipated. This is, however, to be
expected in cases with auricular fibrillation of short duration and with rheu¬
matic heart disease rather than general cardio-vascular degeneration. It may
also be anticipated when the onset of auricular fibrillation has synchronized
with the first appearance of cardiac symptoms, when marked subjective
symptoms of irregular heart action are present, when mitral stenosis is present
rather than aortic incompetence, and in cases of exophthalmic goitre when the
acute stage of the disease has subsided naturally or after thyroidectomy.

(3) That cases in which normal rhythm has been restored tend to relapse
into fibrillation. This is to be expected in cases of long standing fibrillation
with large hearts in which active myocardial disease is in progress.

(4) That the administration of quinidine is attended with certain ill effects
and even with considerable danger. In this connexion the following con¬
siderations must be borne in mind : (a) That the toxic effect on the system
generally is approximately proportional to the dosage. ( h ) That the toxic effect
of the drug in producing decompensation or sudden death is to be expected in
patients with large hearts who have remained poorly compensated on digitalis
therapy, (c) That embolism is to be expected in cases of mitral stenosis with
long standing fibrillation and presumably in patients who have previously
experienced embolic manifestations.

Therefore in determining whether a given case is suitable for quinidine
treatment, we have first to estimate the probability of effecting the restoration
of sino-auricular rhythm. This procedure in itself is not necessarily thera¬
peutic. If a successful physiological action of the drug seems probable, the
possibility of producing a good therapeutic result must next be considered.
Against this we have to set the likelihood of speedy relapse and the possible
dangers the patient incurs as the result of taking quinidine.

Summary.

My chief conclusions may therefore be summarized as follows :—

(1) That the value of restoration of normal rhythm must be judged, not by
the immediate results obtained, but by the patient’s efficiency when he has
returned to his ordinary vocation.

(2) That in the absence of active myocardial disease, the restoration of
normal rhythm with quinidine restores cardiac efficiency to its original level
before the onset of auricular fibrillation.

(3) That in the majority of cases this procedure raises cardiac efficiency to
a higher level than the digitalis treatment of the same condition. In about
half these cases clinical improvement i3 striking but in the other half not
pronounced. In a small minority of cases cardiac efficiency is definitely
reduced.

Cotton: Quinidine in Cases of Cardiac Disease

(4) That the quinidine treatment of auricular fibrillation is contra-indicated
during the acute stage of exophthalmic goitre, but that it may be instituted with
benefit during the more chronic stages of the disease or after thyroidectomy.

(5) That in the successful cases, the prophylactic administration of quini¬
dine should be continued indefinitely. If this is practised relapse does not
necessarily occur over quite long periods.

(6) That the following system of procedure should be adopted : In the
absence of the special contra-indications already discussed, quinidine should
be administered in all cases of recent onset (one year or less). It should not
be administered in cases of long-standing fibrillation (three years or more)
who remain well compensated on digitalis. In cases of moderate duration (one
to three years) and in doubtful cases, the therapeutic possibilities of the
treatment and the risks incurred must be explained to the patient, who should
be allowed to make his own decision.

(7) That the maximum dosage on the standard system described should be
limited to 9 gr. six-hourly.

Finally, I believe that the therapeutic results, which are obtained by the
careful administration of quinidine, justify the slight risks incurred in the
treatment of selected cases.

Dr. T. F. Cotton.

My remarks are based on the experience which I have had during the past
two years in the treatment of patients with quinidine outside the wards of
a public hospital and on the results of treatment in the wards at University
College Hospital, in the clinic of Sir Thomas Lewis.

My impression is that quinidine therapy in private practice is very much
in the hands of the consultant. This, 1 think, is desirable in the present
state of our knowledge. The general practitioner can and does recognize
auricular fibrillation without the aid of the galvanometer or the polygraph.
He knows from the many articles appearing in the medical journals that
quinidine given by the mouth in cachets will restore a normal rhythm in
a percentage of these cases. He has read of the contra-indications and the
danger signals, and hesitates to undertake treatment on his own responsibility.
He fears sudden death, the onset of failure and embolism. He seeks the
advice of a consultant and is glad to entrust to him the management of
the case. I think this is the experience of many of us in dealing with
auricular fibrillation.

The main object of establishing a normal rhythm is to recover the
ventricular rate which was present before the onset of auricular fibrillation.
The ventricular rate is usually high when the auricles are fibrillating, and in
consequence of this high rate an extra load is placed upon the myocardium
already damaged by disease. This is one of the principal causes of heart
failure of the congestive type. One can keep the ventricular rate within
normal limits by giving digitalis. Quinidine obviates the necessity of continuous
digitalis administration. It is no hardship, nor is it inconvenient for the
patient with signs of failure, to take digitalis for the remainder of his life.
Some patients of this class cannot tolerate digitalis in any form, and the
ventricular rate remains high. One would like to give quinidine. I tried
quinidine in one of these cases, but with the very high ventricular rate
alarming signs of failure developed and I was obliged to discontinue its
administration after two days.

Section of Therapeutics and Pharmacology 39

In patients with considerable enlargement of the heart, it is possible to
induce a normal rhythm. I have given quinidine in these cases not so much
with the object of reducing the heart rate, for I could do this with digitalis,
but with the hope of relieving distressing palpitation so common in these
patients. I have combined digitalis and quinidine in these cases, as I feared
the onset of failure from the high ventricular rate if quinidine were given alone.
In all cases in which I have been able to restore a normal rhythm it has
been of short duration.

In patients with slight or moderate enlargement and mitral stenosis, with
no signs of failure or infection, I have never seen the development of symptoms
that were in any way alarming, except in one case. A normal rhythm
returned in about half of them ; some reverted to fibrillation. In a few the
normal rhythm was present when they were last seen.

The most suitable case for quinidine is the young person without enlarge¬
ment of the heart and no valvular disease, who develops auricular fibrillation
after an infection or from some other cause. He is fit in every way until the
onset of auricular fibrillation. With the new rhythm established, physical
exercise easily produces signs of distress. His exercise tolerance is poor;
he is no longer able to continue with his occupation if it is in any way arduous,
and games like tennis, which he enjoyed, he can no longer play. With the
normal rhythm restored, he is able to resume his normal life.

Another type of case suitable for treatment is the patient with a history of
paroxysmal fibrillation, and auricular fibrillation established, i.e., of a few
months* duration; the chances of a return of the normal rhythm are better
than 50 per cent, in this class.

In paroxysmal fibrillation the attacks are fewer and of shorter duration if
quinidine is given in small doses over a period of months. I am not sure
that this holds good in simple paroxysmal tachycardia, though I have seen
considerable benefit in such cases.

I have not seen any good results from quinidine administration in patients
with extrasystoles.

With a history of embolism I would not attempt to restore a normal
rhythm. The risk is, I believe, too great, of dislodging a mural thrombus
when the auricles have again begun to contract.

Briefly, these are my views concerning quinidine therapy. The indis¬
criminate use of this drug in auricular fibrillation is not justifiable. It should
be given a trial in those cases of auricular fibrillation of recent origin presenting
few signs of structural disease, i.e., little or no enlargement, no valve disease
or early mitral stenosis. The failures and successes will be about equal in
this group. A large majority of those with a normal rhythm will again
be fibrillating within two years. If, after six months of normal rhythm, the
auricles again fibrillate, quinidine may be expected to restore the normal
rhythm a second time, the heart reacting to the drug very much as when
first given. If the auricles fibrillate within a period of six months, I do not
think much is to be gained by again restoring the normal rhythm.

In the treatment of paroxysmal tachycardia with the auricles contracting
regularly or fibrillating, quinidine has an important place. In those cases with
paroxysms of long duration and frequent occurrence, much may be expected
from quinidine administration given in small doses and over a long period.
Paroxysmal tachycardia is a serious disability where there are signs of
structural disease present. The results from quinidine in these cases are
quite good.

40 Cotton—Weber: Quinidine in Cases of Cardiac Disease

I am not sure that it is not an advantage to continue with the quinidine
after the normal rhythm has returned, with a view to preventing the recurrence
of fibrillation. In paroxysmal fibrillation and simple paroxysmal tachycardia,
I give quinidine in small doses, 0*2 grm. three or four times daily for months.
This may be good practice in all cases : I have certainly not seen any harmful
results from quinidine given in this way.

I have had one case of sudden death after 2*0 grm. of quinidine had been
given in the usual way. The patient was a woman aged 50 with moderate
enlargement, no valve disease, and a ventricular rate of 140-150 after slight
effort. There were no signs of venous engorgement and no breathlessness
at rest. The nurse had left her reading a book and quite comfortable ; when
the nurse returned a quarter of an hour later, she found her dead, lying in the
same position. There was no autopsy. Death may have been due to
ventricular fibrillation. I have seen the same thing happen with digitalis.
I do not know whether quinidine was responsible for death in this case.

Signs of embolism have not occurred in any of my cases.

I have always given quinidine to private patients with auricular fibrillation
in a nursing home. Few patients require longer than a week’s stay.
If at the end of a week the normal rhythm has not returned, I dismiss the
case as a failure. I insist on absolute rest in bed with the avoidance of all
unnecessary movements. These precautions are taken to prevent giddiness—
a symptom of which complaint is often made—and to ward off syncopal attacks
which are particularly alarming to the patient, the nursing staff, and some¬
times to the physician. The giddiness I attribute to the rapid heart action—
a quinidine effect—and the syncopal attacks are probably vagal in origin.

A test dose of 0*2 grm. quinidine sulphate is given on the day of admission,
and if there is no idiosyncrasy for the drug, on the following day I give
four doses of 0*4 grm. at intervals of three hours. On the third day I add
an extra cachet, and from this time onwards the patient has 2 grm. daily.
It is, of course, not possible to observe the effect of quinidine on the auricular
rate without a galvanometer and chest leads. This is really not a serious
handicap. With a return of the rhythm to normal it is easy to recognize the
change with a stethoscope. Occasionally, the heart is irregular after auricular
fibrillation has ceased from extrasystoles. It is best in these cases to make
certain of the type of irregularity by taking a polygraphic tracing.

Dr. Iliescu has kindly given me the figures to date of cases treated in the
clinic of Sir Thomas Lewis at University College Hospital. Quinidine was
given in forty-two cases of established auricular fibrillation. The patients
reverted to their normal condition in twenty-five (or 59 per cent.) of these
cases. Ten have remained normal; seven for more than a year. Fibrillation
returned in 50 per cent, of the cases with a normal rhythm restored within
two weeks. Apparently, in these cases the successes and failures seemed to be
quite independent of age, venous congestion, infection, type of valve disease,
or degree of enlargement. Those with a long history of fibrillation were
restored to their normal state as quickly as others with fibrillation of short
duration.

Dr. F. Parkes Weber

said he wished to draw attention to a possible danger in connexion with quin¬
idine treatment for auricular fibrillation.

A well-built Englishman, aged 60, was admitted to hospital with cardiac irregularity
typical of auricular fibrillation. Swelling had been noticed in the legB in the evenings.

Section of Therapeutics and Pharmacology 41

The heart was slightly enlarged to the left, but there was no definite murmur. The
hepatic dullness extended too far downwards. The treatment, at first, wets by prepara¬
tions of the digitalis class, including intravenous injections of Boehringer’s strophanthin ;
but the cardiac irregularity persisted till quinidine sulphate was given (in doses of
0‘2 grm. thrice daily). Then, within a week, the pulse became perfectly regular (con-
finned by careful sphygmograms). By ordinary examination there seemed to be
nothing wrong with the man, excepting that his liver dullness still extended somewhat
too far downwards; but his blood-serum was found to give a strongly positive Wasser-
mann reaction. It was then ascertained that he had had a chancre thirty-four years
ago, for which he had been treated, but he could not remember having had any
symptoms of secondary syphilis. His wife had had one miscarriage, not long after
marriage, and had never become pregnant again. Antisyphilitic treatment was com¬
menced. The auricular fibrillation in this case may have been due to cardiac syphilis,
and no history of rheumatic fever could be obtained.

There seemed to be a real danger in such cases that the disappearance of the
auricular fibrillation under quinidine treatment might occasionally lead to the
overlooking of syphilis as the main cause of the cardiac trouble. Thus, the
cardiac disease might be allowed to progress, owing to the syphilitic factor
remaining unrecognized, until antisyphilitic treatment was no longer of any
avail.

Dr. Weber said he was indebted to his colleague, Dr. E. Schwarz, for the
history of the first part of the above case, during a time when he (Dr. Weber)
had been away from London.

Dr. B. T. Parsons-Smith

said that the subject of quinidine therapy was of extreme importance, for in
spite of very extensive investigation the indications and usage of the drug had
not yet emerged from their probationary stages.

His opinion was that quinidine was a valuable and at the same time a
somewhat dangerous drug, in essence a powerful depressant and poison to
cardiac muscle tissue, and in some degree to the autonomic nervous system
controlling the heart's mechanism. Certain unfortunate features were in¬
variably associated with quinidine therapy: First, the uncertainty of its
action, which would appear to depend in great measure upon the inability
to assess during life the varying types of pathological anatomy which under¬
lay auricular fibrillation, and, secondly, the possibility of serious disturbances
of rhythm, ventricular tachycardia, premature contractions, ventricular stand¬
still, &c., during the transition stages. He (Dr. Parsons-Smith) particularly
emphasized the remarks of Dr. Drury that quinidine therapy should, for
the present, only be employed in those circumstances under which strict
observation and graphic control of the cardiac mechanism could be con¬
veniently practised, and this would involve full in-patient treatment in
every case.

Extreme care should be exercised in the selection of cases for treatment
by quinidine. Those patients in whom the fibrillation had been of recent onset
and in whom the signs of myocardial degeneration were not advanced in
degree, should be especially chosen ; and at the same time cases of long standing
with signs of gross failure should not be wholly excluded if there was
any reasonable chance of subjective improvement following the reversion from
fibrillation to the normal auriculo-ventricular rhythm.

He thought it very necessary to bear in mind that quinidine was by no
means a substitute for digitalis in auricular fibrillation ; the respective values

42 Parsons-Smith: Quinidine in Cases of Cardiac Disease

of the two drugs, as it happened, being frequently complementary, were set
in entirely different spheres, and depended upon the production of effects
which were diametrically opposed in certain important respects.

He (Dr. Parsons-Smith) would lay stress upon one other noteworthy factor,
namely, the lowered excitability of the whole cardiac musculature which
quinidine in certain cases had a tendency to produce. Clinical experience had
already suggested to him that the diminished excitability was by no means a
temporary event, but that on the other hand a raised threshold of excitation
was likely to persist for a varying period following quinidine medication.
This was well exemplified by certain cases of fibrillation, in which the heart
failed to revert to the normal rhythm under quinidine, but was later con¬
trolled by smaller doses of digitalis than had formerly been needed under
similar conditions of work and daily routine.

He fully endorsed Dr. Cotton’s remarks with regard to the possibilities
of quinidine in cases of paroxysmal tachycardia, his experience in these types
of disorder leading him to consider that permanent improvement might
ensue, and further that a full trial of the drug was warranted in serious
cases of this nature.

Section of Gberapeutics anb pharmacology

President—Dr. W. Langdon Brown.

The Idiosyncrasies to Drug Tolerance of Animals as
compared with Man.

By W. Hamilton Kirk, M.R.C.V.S., Captain R.A.V.C.

PROBABLY only a small minority of men can claim the distinction of
presenting to the Fellows of this Society, any facts which are entirely new
to science; but in presenting this subject to the Section this afternoon, I hope
that the comparisons I shall draw, will, at least, interest clinicians, and especially
those who are unacquainted with the effects of drug administration on the
domesticated animals.

That many species of animals, besides individuals of the same species, no
less than human beings, show marked idiosyncrasies to the actions and doses
of various drugs, is well known.

Perhaps the best illustration one can give, is the extraordinary effect of
morphine upon the pig and the cat. In these animals it causes excitement and
convulsions, though it proves an excellent hypnotic for man and the dog.
Again, a peculiar power of resistance to the action of atropine seems to be
inherent in monkeys and rabbits. In the human, canine, and equine species,
belladonna accelerates cardiac action on account of its paralysing action on
the vagus, the normal restraint or control exercised by this nerve over the
heart being thus counteracted. But in rabbits, the vagus plays so small a
part in the regulation of the heart beat, that far larger doses of belladonna
may be given them without any appreciable increase in the rapidity of the
heart beat being produced. It would require as much as 15 gr. of green
extract to poison a rabbit. For a similar reason, a marked difference is
observed in the action of amyl-nitrite on rabbits as compared with its effect
on dogs. Such observations are not only interesting in themselves, but
appreciably help to enhance our comprehension of the action of drugs.

Tartar emetic , a few grains of which cause almost immediate emesis in
dogs and pigs, has no such physiological effect on either horses, cattle, or
sheep; a fact which is readily understandable as regards ruminants, but which
is somewhat more difficult of explanation in the case of the horse. Again,
apomorphine, which promptly causes vomiting in dogs, has no emetic action on
pigs. It is thought by some authorities that the insusceptibility of the horse
to the action of emetics is ascribable to an inaptitude of the vagus nerve to
receive and convey the special irritation; but more probably it is due to
imperfect development of the vomiting centre (oblongata). Many substances
which exert an emetic action on men and dogs are supposed to produce

Aug— Th 1 f April 10, 1923.

44 Kirk: Drug Tolerance of Animals as compared with Man

sedative effects when given to horses in sufficient doses. 1 But with one or
two exceptions, the many sedatives available in human and canine practice
operate uncertainly and imperfectly on horses, for which aconite still remains
a reliable and valuable sedative medicine (cardiac and respiratory).

“ A medium-sized Scotch terrier was once given 30 minims of Fleming’s
tincture. In five minutes, painful and active vomiting ensued, which must
have effectually emptied the stomach. The retching and vomiting continued,
however, for half an hour, when the animal was so exhausted and paralysed
in its hind extremities as to be unable to walk, except by supporting itself on
its fore limbs and dragging the hind quarters. It gradually recovered,
however, in about two hours, in spite of the phenomenal dose (normal dose
i minim to 1 minim). In some cases a drachm of Fleming’s tincture has
destroyed dogs with as much rapidity as an equal quantity of prussic acid.” 3

Cattle require very large doses of all medicinal agents in order to produce
any effect upon them, and considerable quantities of some of the irritant and
corrosive poisons can be given them with comparative impunity. This is
largely accounted for by the fact that the stomach of an ox is divided into
four portions, and as regards its first three divisions it is less vascular. Its
function is much more mechanical and less chemical than the corresponding
portion of the alimentary canal of men, dogs, or horses. Further, the first
and third compartments (rumen and omasum) always contain food, often in
large quantity. Such a set of circumstances would explain why purgatives,
unless in large doses and in solution, are so tardy and uncertain in their
effects. Aloes when given to cattle even in the fluid state and in doses of
several ounces, fails to produce copious evacuations; and nothing under 1 lb.
of mag. sulph. is of much avail for the cow as an aperient. A notable
exception to the rule that cattle can tolerate much larger doses of irritants
than horses is their susceptibility to calomel . Irritant effects, followed by
constitutional disturbance, are produced in horses by 3 to 4 dr.; but in cattle
by 2 dr.

On dogs, medicines generally operate much in the same way as upon man, but
to this rule there are also some remarkable exceptions. Dogs, for instance, take
30 gr. to li dr. of aloes , which is several times larger than the dose usually given
to human patients ; but they might be seriously injured by half as much calomel
or oleum terebinth as is prescribed for man. The opinion generally held, that
medicines may be given to dogs in the same doses as to man cannot therefore
be safely entertained without some reservations. In consequence of the
relatively large size of the dog’s stomach, combined with a short and straight
intestinal tract, purgatives act upon them with far greater rapidity than they
do upon other veterinary patients. Among them all, we find that most
medicines work with greater certainty and effect upon well-bred animals than
upon coarsely-bred mongrels, and it is a matter of conjecture as to whether
the same distinction could be drawn in human practice. Having made a short
survey of the subject I will now proceed to particularize briefly on two or
three selected alkaloids.

Morphine .—The effects of morphine may vary in the same individual
according to the dose given, and in man and the lower animals, according to
the relative development of the several parts of the central nervous system.
In man morphine acts specifically and primarily upon the higher brain centres,

1 Tartar emetic has a sedative effect on horses.

- “ Experiments at Royal Dick Veterinary College.”

Section of Therapeutics and Pharmacology

which are depressed, and the patient is usually calmed and sleeps, and after
large doses becomes comatose. In some of the lower animals, a stimulation of
the locomotor centres of the brain, and of the reflex centres of the cord, is
manifested; thus, instead of being quieted and hypnotized, they are at first
excited, exhibiting irregular involuntary movements, and after toxic doses,
tetanic convulsions and a coma, from which however they can be readily
roused. In some veterinary patients the prominent phenomena are agitation
or unrest, inco-ordinated movements, vomiting, diminished sensibility to pain,
and in toxic doses—convulsions, coma, and death by respiratory arrest. The
more highly an organ is developed, the more susceptible does it become to the
action of certain drugs, and this general law explains why the highly developed
human brain is specially susceptible to the effects of such cerebral medicines
as opium and chloral; and why frogs and cats, whose spinal systems are
better developed than their brains, are so susceptible to strychnine, which acts
specially on the cord. Whilst the human cerebrum is, I believe, more than
seven times the weight of the mesencephalon and cerebellum, we find in
domestic animals that the cerebrum is only five times the weight of the
posterior parts of the brain, the cord being relatively larger than in man.
These differences of development explain how such drugs as opium, chloroform
and chloral produce blunted intellectual function and deep stupor in man,
whilst in the lower animals they produce less marked depression of brain
function, but with more marked derangement of motor function and convulsions.
Horses , with less development of these higher brain centres, have relatively
more development of the locomotor centres and of the reflex centres of the
spinal cord, and upon these lower centres, opiates in equine subjects exert
their primary stimulant effects. Full doses produce, at first, restless involuntary
movements of the head and limbs, pawing the ground, or walking continuously
round the box; this is followed by sleepiness, disinclination to move, and when
the horse is moved, by staggering. Excessive doses cause tetanic convulsions,
although I have repeatedly injected as much as 20 gr. of the hydrochloride
subcutaneously into a horse without producing the slightest toxic symptom.
This would occur, of course, during a severe attack of colic, when a horse is
able to withstand much larger doses than it would in the absence of pain.
The average dose ranges from 3 to 10 gr. Horses will, with impunity, take
by the mouth about one hundred times as much opium as would poison a man.
Ruviinants are affected in very much the same way as horses, that is, they
become excited and restless. Cattle bellow, and sometimes digestion is
impeded and tympanites frequently supervenes. One cannot readily induce
sleep in them, except by the influence of full and repeated doses. Dogs exhibit
effects more nearly comparable to those observed in man. Relatively to their
body weight they take eight to ten times the dose prescribed for human beings.
They show less involuntary muscular movement than the horse, and little or
none of the excitability of the cat. Sleep is never profound ; in fact, dogs are
quite easily aroused. They seem to dream and have hallucinations, and, after
a full dose, remain stupid for a whole day. The average hypodermic dose of
morphine is 1 gr., but terriers can tolerate 2 gr. quite safely, whilst some of the
larger breeds will stand as much as 5 gr. without exhibiting toxic symptoms. 1

i Hobday considers that the range between the narcotic and toxic dose in the dog is so great,
that it is almost impossible to produce poisoning. He once administered 27 gr. to an old poodle
suffering from cancer in the throat, the dog recovering some twenty-two hours later sufficiently to
be able to walk and drink.

46 Kirk : Drug Tolerance of Animals as compared with Man

The pupil is nofc dilated, as frequently happens in the horse and cat,
nor continuously contracted, as in man; but it has been observed to be in
a state of contraction during narcosis. Cats become very excited under the
influence of morphine, tearing round the room, or running up the curtains in an
alarming fashion ; hypnosis is produced in them with such difficulty, that
morphine plays no part in feline practice. In rabbits also the motor and spinal
centres are prominently affected, and convulsions are more common than
hypnotism. Birds are curiously insusceptible, for relatively to their weight
they are stated to take three hundred times the human dose and do not sleep
or show any alteration of the pupil. Morphine convulses frogs , but, even in
large doses, has no effect on pigeons except in reducing their temperature.

Cocaine .—I read that the outstanding symptoms of a toxic dose of cocaine
in man are vertigo, faintness, small rapid pulse, and prostration, and that the
antidotes recommended are stimulants, amyl nitrite, and artificial respiration.
As I do not indulge in the practice of administering overdoses to my own
patients, I cannot produce any extensive statistics of personal observations in
cocaine poisoning. But to show the idiosyncrasies of some dogs in regard to
the amount of cocaine they can tolerate, I will relate an instance which recently
occurred in my practice, in which a dose of this drug—regarded usually as a
normal and safe amount—proved to be thoroughly toxic. The patient was an
aged terrier, in somewhat poor condition,and of about 25 lb. body-weight, afflicted
with multiple neoplasms. I injected 25 minims of an 8 per cent, solution into
various parts of the body surface, and within three minutes a brief stage of
clonic convulsions was manifest, which almost immediately became tonic, the
eyes rolling and the dog profusely salivating and licking its lips. Only a very
few more minutes elapsed before opisthotonos was well marked, and all limbs
rigidly extended and cold; respiration considerably slowed and the pulse
hardly perceptible. Syrup of chloral was at once administered per os, and
followed up by the application of chloroform to the nostrils. As life
appeared to have become extinct, artificial respiration was commenced and
persisted in for half an hour ; signs of recovery then became evident,
and the dog's state was considered safe. The after-effects were very curious,
the animal being quite unable to remain still a moment, or to decide how or
where to rest in its basket. It moved constantly in a circle, sometimes
getting one leg over the side and occasionally falling out. It would crouch
as if in fear when shouted at, or when pretence was made to strike it. The dog
would then remain still for a few moments, only to resume its extraordinary
gyrations. Another peculiarity was the repeated attempt made by the dog to
raise its hindquarters in the air; it then stood only on its front legs, and as
often as not would lose its balance. Although the operation was performed at
6 p.m., the after-effects had not wholly subsided until about 10 o’clock the next
morning. I had used 2 gr. of cocaine on many previous occasions without
any more alarming symptoms than salivation and licking of the lips, both
of which seem inseparable from the use of this drug. In no text-book
other than Hobday's “ Veterinary Anaesthetics " have I seen reference to this
constant manifestation—salivation, although it is a symptom which can be
demonstrated in dogs almost immediately after every administration of
cocaine, whether in toxic dose or not. The toxic phenomena observed in this
clinical case are not strange to canine practitioners, and they serve to show
the great dissimilarity of the manifestations of cocaine poisoning in man as
compared with those seen in members of the genus Canidse. Horses may
be given any quantity up to 10 gr., but even as much as 80 gr. injected

Section of Therapeutics and Pharmacology

subcutaneously has been sometimes found insufficient to kill. Such an amount
would render a horse very restless and excited ; it would paw with its fore feet,
neigh, and appear timid ; the pulse would increase in rapidity to about double
the normal rate (90) ; salivation would occur, and the pupil would dilate. At
the end of an hour, however, its condition would be one of frenzied excitement,
with a greatly augmented reflex activity. Probably after the lapse of a further
two hours, these effects would disappear. Cattle respond in a similar fashion,
and the injection of 1 dr. is stated to produce excitement bordering on madness,
and continuing for four hours, but gradually passing off, and leaving no in¬
jurious effect. Dogs should never receive more than to gr. of cocaine per
pound of the body weight; those receiving more than this amount exhibit
psychical excitement, tetanic and clonic spasms, epileptic fits, loss of co¬
ordination and dyspnoea. The spasms and more prominent symptoms, how-
ever, do not occur when potassium bromide or ether have previously been given.
Hobday states that 12 to 15 gr. kill small dogs in ten minutes. It may,
perhaps be mentioned in passing that the South American Indians and the
natives of several other countries have for centuries been in the habit of not
only eating coca leaves themselves, but also of giving them to their horses, to
diminish the sense of fatigue, thirst, &c. From this custom has doubtless
arisen the more modern practice of doping racehorses, in order to produce in
them such temporary excitement and vigour as will enable them to win.

Strychnine .—The action of strychnine is almost identical throughout the
vertebrate kingdom, but there are marked differences in the amounts which
the various animals can tolerate with safety. As I have already mentioned,
human posology more nearly resembles that of the dog than of any other
animal, but in the case of strychnine, dogs are decidedly more susceptible than
man. Thus, whilst an adult terrier should receive no more than ^ gr., man
can safely take iV gr. Dogs may be destroyed in twelve minutes by i gr. of
strychnine, and in two minutes by i gr. (Christison). I knew of a case in
which a Pekingese picked up and inadvertently swallowed an Easton's syrup
capsule, the*contents of which were presumably equivalent to 1 dr. of the
syrup, and was dead within ten minutes. This, however, is rather exceptional.
The toxic dose for an average dog may be regarded as about xV gr* Cats,
which usually tolerate half the dose for the dog, would be greatly endangered
if given more than £ of the canine dose. In practice I rarely prescribe a
greater dose of strychnine for cats than gr. Horses and cattle are not by
any means so readily affected as men and dogs. Given hypodermically, the
toxic dose for horses is stated by Frohner and Kaufmann to be from 3 to 6 gr.;
whilst the safe medicinal dose is 1 gr. To prove the assertion that cattle
withstand larger doses than do horses, when administered by the month,
Macgillivray (a veterinary surgeon) gave an aged cow 30 gr. of strychnine, and
shortly afterwards 60 gr., both doses in solution, with the result of a few
spasmodic tremors which continued for about twenty minutes. Very much
smaller doses are fatal when the strychnine is quickly absorbed. Thus
Kaufmann states that the lethal hypodermic dose is 5 or 6 gr.; but several
cases have occurred recently in w^hich practitioners have administered only
1 gr., with unexpected fatal results. Consequently it is now a much more
common belief that cattle are, in reality, more susceptible to strychnine than
are horses, though I am at a loss to explain why they should be. Pigs are
violently convulsed and poisoned by £ to £ gr., whilst the domestic fowl
tolerates comparatively large quantities without symptoms.

PROCEEDINGS

OP THE

KOYAL SOCIETY OF MEDICINE

EDITED BY

Sir JOHN Y. W. MacALISTER

UNDER THE DIRECTION OP

THE EDITORIAL COMMITTEE

VOLUME THE SIXTEENTH

SESSION 1922-23

ECTION OF TROPICAL DISEASES & PARASITOLOGY

LONDON

LONGMANS, GREEN & CO., PATERNOSTER ROW

1923

Section of tropical Diseases anb jparasitoloas

OFFICERS FOR THE SESSION 1922-23.

President —

Lieut.-Colonel Sir Leonard Rogers, C.I.Fi., M.D., F.R.S., I.M.S.

Vice-Presidents - -

Leonard S. Dudgeon, C.M.G., C.R.K., F.R.C.P.

Lieufc.-General Sir John Goodwin, K.C.B., C.M.G., D.S.O.,
F.R.C.S., A.M.S.

Vice-Admiral Sir Robert Hill, K.C.B., K.C.M.G., C.V.O., R.N.
Aldo Castellani, C.M.G., M.D.

Hon. Secretaries —

R. T. Leiber, M.D., D.Sc.

W. T. Prout, C.M.G., O.B.K., M.B.

J. B. Christopherson, C.B.E., M.D.

Lieut.-Col. H. Marrian Perry, O.B.E., R.A.M.C.

Other Members of Council —

W. Broughton-Alcook, M B.

R. II. Elliot, M.D.

Wing-Commander C. B. IlRALD, C.B.E., R.A.F.,

Lieut.-Colonel Robert McCarrison, M.D., I.M.S.

J. Ramsbottom, O.B.E.

J. Gordon Thomson, M.B.

Lieut.-Colonel Edmund Wilkinson, F.R.C.S., I.M.S.

L’epresenlatiee on Library Committee —

W. T. Prout, C.M.G., O.B.E., M.B.

Jlepresentaticc on Editorial Committee —

Aldo Castkllani, C.M.G., M.D.

SECTION OF TROPICAL DISEASES
AND PARASITOLOGY

CONTEN T S.

November 6 , 1922 .

Lieutenant-Colonel H. Marrian Perky, O.B.E., R.A.M.C. page

Some Observations on the Occurrence of Leislirnania in the Intestinal
Tissues in Indian Kala-Azar ; on the Pathological Changes occasioned
by their Presence, and on their possible Significance in this
Situation ... ... ... ... ... ... ... 1

M. Khalil, M.D., Ph.D.

A Description of Gastrodixc.oiiles hominis, from the Napu mouse deer ... 8

February 5 , 1922 .

Arthur Powell, M.B.

Frambccsia : History of its Introduction into India; with Personal

Observations of over 'J00 Initial Lesions ... ... ... 15

March 5 , 1923 .

G. M. Vkvkrs, L.It.C.l’.Loiul.; M.R.C.S.Eng.

The Lung Flukes of the genus ParayoniDiux : A Demonstration ... 43

R. J. Ortlk HP.

Life-history of the Gape-worm (Abstract) ... ... ... ... 44

Wing-Commander II. E. Whittingiiam, R.A.F.M.S.

Life-history of the Sandfly, Phlrhotomun papataaii (Abstract) ... ... 45

W. Broughton-Alcouk, M.B.

Case of Spirochietal Dysentery (Abstract) ... ... ... ... 46

J. B. Christophkrson, O.B.E., M.D.

Remarks upon a Photograph of an Endemic Focus of Bilharzia Disease
in Portugal; Specimens of the Intermediary Host, Planorbis
fhtfvurii (Graells)

Contents

Andrew Robertson, M.B. pag*

Specimens from a Human Case of Infection with Dientamcnba fragilu ,
Jepps and Dobell, 1917 ... ... ... ... 48

May 7, 1923.

A. E. Hamkrton, C.M.Ct., D.S.O., Lieutenant-Colonel R.A.M.C.

The Establishment of an Antirabic Institute in the Tropics ... ... 49

Exhibited by J. B. Chbistopherson, C.B.E., M.D.

Specimens of (1) Schistosoma bovis and of its Snail Carrier; (2) the

Intermediate Hosts of Schistosoma mansoni , Brazil ... ... 5$

.:ne

The Society does not hold itself in any way responsible for the statements made or
the views put forward in the various papers.

John Batk, Sons A Danikuwon. Ltd., SS-91, Gre»t Titchtteld Street, London. W. 1.

Section of (Tropical Diseases ant> parasitoloap.

President — Sir Leonard Rogers, C.I.E., M.D., F.R.S., I.M.S.

Some Observations on the Occurrence of Leisbmania in the
Intestinal Tissues in Indian Kala-Azar; on the Patho¬
logical Changes occasioned by their Presence, and on
their possible Significance in this Situation.

By Lieutenant-Colonel H. Marrian Perry, O.B.E., R.A.M.C.

SINCE the discovery by Leishman, in 1900, of the infecting organism of
Indian kala-azar, the cutaneous and visceral infections caused by these
parasites have attracted considerable interest.

Notwithstanding the widespread research into the possible methods of
transmission of the visceral form of the disease, we are still without informa¬
tion regarding the means of its transference from man to man. There are,
however, other aspects of this infection on which more exact information is
available. The pathological changes encountered in fatal cases of visceral
leishmaniasis are now well recognized, and the situation and distribution of
the parasites in the tissues have been more or less defined. In any con¬
sideration of the pathology of the disease, it is evident that the most pre¬
dominant feature is the early increase in size of the liver, and more particularly
of the spleen. The great enlargement of the latter organ, resulting from an
increase in the splenic pulp, is caused by the enormous proliferation of lymphatic
and vascular endothelium. The distribution of the Leishmania bodies is typi¬
cally as intracellular parasites of these hypertrophied endothelial cells, and,
although occurring in largest numbers in the spleen, liver and bone marrow,
these protozoal organisms have been demonstrated in almost every other tissue
of the body. They are fairly abundant in the bone marrow, and have also
been observed in smaller numbers in the kidneys, the suprarenals and in the
pancreas. It is a matter of comment that less attention appears to have been
directed to the distribution of the parasites in the gastro-intestiqal system, and
to the changes resulting from their presence in this situation.

In reviewing the literature dealing with this aspect of the pathology of the
infection, it is noted that most of the observations appear to have been directed
to the gross lesions which are found in the large intestine in many cases of
the disease. Christophers [l] comments on the fact that it is common in
India to find a widespread multiple ulceration in this part of the bowel, the
ulceration extending deeply into the muscular coat of the intestine. In some
of his cases amoebae have been found in the ulcers and associated liver abscess

F—Tr 1 [November 6, 1922.

2 Perry: Observations on the Occurrence of Leishmania

has been present, evidently coincident infections with Entamoeba histolytica .
Jemma and Di Christina [2] note the constant occurrence of an enterocolitis
in cases of infantile kala-azar, and the presence in the large intestine of circular
ulcers with elevated edges. These latter observers have further found on
microscopic examination that these lesions were associated with a small
round-celled infiltration of the mucosa and muscular coat, together with dilata¬
tion of the lymphatic vessels and hypertrophy of the endothelium in which
Leishmania parasites were sometimes present. Christophers also records the
presence of Leishmania as intracellular parasites of endothelial cells lining the
blood-vessels in the granulation tissue of ulcers in the large intestine, whilst
Archibald [3], writing on the pathology of the infection, states that in his
experience of the visceral form of the disease the stomach and small intestine
are not commonly affected, but that the large intestine may show congested
and ulcerated areas in the greater part of its length.

In this brief review of the pathology of the disease as it affects the gastro¬
intestinal system, it will be noted that no observations are recorded relative
to changes in the small intestine. It is in connexion with certain microscopic
appearances seen in this portion of the intestinal tract in two fatal cases of
the Indian variety of the disease that this communication is made.

The material available for investigation, and on which the observations
that follow are based, consisted of small portions of the jejunum, which, as
far as macroscopic appearances are concerned, would not have been considered
abnormal at post-mortem examination. On closer investigation, the mucosa
could be seen to be slightly thickened, the other coats of the intestine being
normal in appearance. No evident breach of surface or ulceration was
apparent in the mucous coat of the portions of tissue examined. The micro¬
scopic investigation of sections made from various parts of these tissues
demonstrated a very consistent and interesting pathological picture. The
changes observed can be shortly summarized as follows :—

The histological appearance of the serous, muscular and submucous coats
differed in no detail from that normally seen in the small intestine. The most
striking change wa3 that evident in the mucous membrane owing to a very
definite and remarkable alteration in the villi. These processes of mucous
membrane had undergone a complete metamorphosis, and, instead of appearing
as slender narrow fimbria as seen in the normal intestine, each villus was
transformed into a swollen, distorted and polypoid body connected with the
submucous tissue by a constricted stalk formed of a few fibres of connective
tissue. The columnar epithelium covering the villi had disappeared and the
basement membrane furnished a delicate limiting sheath for each little swelling.
The internal structure of the villi was completely altered owing to an intense
proliferation of the endothelial cells lining the lymph channels. This prolifera¬
tion of endothelium, although marked in the base of the villi, became more
pronounced towards the centre and extremities of these structures, and the
enlargement and distortion was caused by these tightly packed accumulations
of hypertrophied cells. In the greater number of villi the basement membrane
was intact, but in many instances it had ruptured from over-distension and
liberated the enclosed endothelial cells.

The distribution of Leishmania bodies in the intestine was very striking.
They could be demonstrated in scanty numbers in the submucous coat; in
that position they occurred in endothelial cells evidently derived from vascular
endothelium. They were present in larger numbers, in the same intracellular
situation, in the base of the villi. In the centre of the villi they had under-

Section of Tropical Diseases and Parasitology

gone rapid multiplication, and they were present in enormous numbers in the
endothelial cells distending the extremities of these structures. In many of
the villi numbers of endothelial cells had broken down, and the parasites were
lying free in the villus, mixed with the debris of necrotic cells. Reference to
the figures illustrating the changes observed will enable the striking alteration
in appearance of the villi to be appreciated. I have had the opportunity of
examining spleen and liver sections from a large number of cases of visceral
leishmaniasis, and have not in any case observed an infection of endothelial
cells which would compare numerically with the great numbers of parasites
present in these endothelial villous tumours.

A comparison of the cellular reaction observed in the small intestine in
these cases of visceral infection with that evident in the subcutaneous tissues
in cutaneous leishmaniasis illustrates the close analogy between the pathology
of the two conditions.

In both infections the type of cell involved is the lymphatic and vascular
endothelium, and any difference observed depends entirely on the localization
of the parasites. In the visceral disease, at least as far as the above cases
are concerned, the intestinal villi were heavily infected, and the resulting
endothelial proliferation had formed a series of endothelial villous tumours.
In the cutaneous form of the disease, an oriental sore at its inception is
nothing more than a cutaneous endothelial tumour. The continued accumula¬
tion of endothelial cells, either in the villi or in the cutaneous tissues, eventually
leads by mechanical pressure to a deficiency or obliteration of the blood supply
and consequent atrophy and necrosis of these cells, which finally terminates
in ulceration.

Discussion on the Possible Relation these Observations may have
on Certain Aspects of Indian Kala-azar.

(l) On the Clinical Course and Symptoms of the Disease .

In any clinical description of the disease the progressive wasting and, finally,
the extreme emaciation which occurs in the established infection is emphasized.
Thus, in compiling a table illustrating the differential diagnosis between Indian
kala-azar and chronic malaria, Knowles notes that in kala-azar emaciation is
very marked and sometimes extreme, whilst in chronic malaria it is less
noticeable. Further, the constant recurrence of symptoms referable to the
intestinal tract, such as enteritis, are very commonly observed during the
course of the disease.

That progressive and extreme emaciation should be a common feature in
the clinical picture appears to me not to be surprising if the pathological
changes in the small intestine described above can be shown to be usually
present.

It is obvious that the profound alteration of the intestinal villi must almost
arrest, or at least considerably reduce, the absorption of nutritive substance.
The destruction of the epithelial covering of the villi, combined with the vascular
and lymphatic stasis caused by the pressure of accumulated endothelial cells
in their interior, must produce a complete perversion of their normal physio¬
logical function and render them useless for purposes of nutrition. In a
similar manner it is possible that the recurrent attacks of diarrhoea, so typical
during the disease, may find their explanation in this alteration in structure of
the mucous lining of the bowel.

F—Tr la

4 Perry: Observations on the Occurrence of Leishmania

(2) On Methods of Transmission of the Disease .

In discussing the relationship which these observations on the distribution
of Leishmania parasites in the tissues of the small intestine might be conjec¬
tured to have on the problem of transmission of the disease, I do not wish it
to be assumed that I favour the theory of direct infection of the human subject
by the alimentary route. The knowledge that the infecting parasite of kala-
azar is a flagellate included in the genus Herpetomonas, and that the known
species of this genus find their primary habitat in the intestinal tract of an
insect host, is a very strong argument against the direct transmission of the
organism through the agency of infected faecal material. Admittedly, however,
there are only two possible routes by which the parasites can escape from the
human tissues, i.e., either from the peripheral blood, through the agency of
some blood-sucking ecto-parasite, or from the alimentary canal in the faeces.

The researches undertaken with the view of the incrimination of an inter¬
mediate insect host are ably discussed by Patton L4], who is strongly in favour
of this method of transmission of the disease. He cites numerous experiments
illustrating the longevity and development of the parasites in the intestinal
canal of bugs belonging to the genus Cimex , and quotes the developmental
changes observed by Cornwall in preparations containing the flagellate stage
of the parasite and portions of the mucous membrane of the stomach of Cimex
rotundatus (Hemiptera) “as furnishing final proof that Cimex is the true inter¬
vertebrate host of Herpetomonas donovani."

The recent work of Mrs. Adie [5] in India on the development of flagellates
in the cells of the mid-gut of Cimex hemiptera which had been fed on infected
splenic pulp has been criticized by Wenyon [6] on the grounds that these
observations had been made on bugs which had died after the infecting feed
and had not been examined until after the lapse of some days. The further
observation of Mrs. Adie on the presence and multiplication of the parasites
in the salivary glands of Cimex have not been accepted, the bodies observed
being neither Leishmania nor a developmental phase of some other flagellate.

The possibility of the dissemination of infection by mosquitoes, sand-flies,
lice and ticks has been closely investigated by many observers, but up to the
present the investigation has yielded negative results.

The fact, however, that viable forms of the parasite can be shown by
cultivation to occur in the peripheral blood, and that the incidence of the
organisms in this situation is very much higher than was formerly believed,
favours the view that infection is probably spread from this source by some
insect host. Thus Patton states that it was the exception to fail in finding
parasites in the peripheral blood of his cases in Madras, and Knowles [7]
records the presence of Leishmania in blood films in 45 per cent, of the cases
under his investigation in Shillong.

The present position regarding the problem of transmission of infection
through the intermediary of an insect host can be summarized by the state¬
ment that no conclusive evidence is at the moment forthcoming which would
incriminate any of the above agents.

The second possible method of elimination of the parasite from the human
body being by the faeces, the possibility of direct faecal transmission of the
disease from infected cases to healthy human subjects has received some con¬
sideration and support. Knowles, in discussing this aspect of the problem,
cites the case of a municipal sweeper in Nowgong whose only apparent contact
with infection was in connexion with his conservancy duties. The same

Section of Tropical Diseases and Parasitology

observer figures small oval cytoplasmic bodies found in the dysenteric mucus
of several cases of kala-azar suffering from intestinal symptoms, but he could
not reconcile their nature with any known form of the parasite. Mackie [8]
also noted and recorded the presence in faecal mucus of small cytoplasmic
bodies with a chromatin nuclear structure which he considered indistinguish¬
able from Leishmania : and Minchin, to whom the preparations were submitted,
expressed the opinion that they resembled Leishmania . To obtain a series of
controls, Mackie examined the faeces of twenty-six healthy individuals living
in the same area as the kala-azar cases in which the presence of these puzzling
“ bodies ” was observed. In none of these individuals could he demonstrate
structures of similar appearance. A limited number of feeding experiments
with mucus containing these bodies was undertaken, dogs and monkeys being
employed, but these experiments yielded negative results. Patton, on repeated
examinations, has failed to find any bodies of the nature of Leishmania in the
faeces, and concludes that if the parasites appear in the excreta they do not
occur in their usual round or oval forms. Both Knowles and Patton have
failed to obtain any evidence of development in cultures made from intestinal
mucus. This latter fact is, however, of little importance owing to the impossi¬
bility of obtaining cultures uncontaminated with bacteria.

Feeding experiments with intestinal mucus from infected cases have failed
to give positive results in a limited number of instances as noted above, but
Archibald and others have recently been successful in infecting monkeys by
feeding them on infected splenic pulp.

The possibility of dissemination of the parasites by a helminthic agency
has been investigated, but has failed to help in the elucidation of the problem.

The above very limited survey of the painstaking research work carried
out on the transmission of kala-azar has been given to emphasize the fact
that the problem of the method of spread of this disease still awaits solution,
and that any fresh observations relative to the pathology of the infection
deserve consideration.

In an earlier part of this paper it has been recorded, in the description of
the pathological appearances observed in the small intestine in two cases of
the disease, that the localization of the parasites was mainly in the intestinal
villi, and that there was evidence of intense multiplication in this situation
leading to an enormous increase in their numbers in the extremities of these
structures (fig. 2, p. 7). The delicate nature of the sheath enclosing these little
swollen processes of mucous membrane was mentioned, also the fact that in
many of them this had ruptured and liberated the enclosed parasites and
endothelial cells into the lumen of the intestine (fig. 3, p. 7). It is possible, and
indeed even probable, that in many instances this rupture of the villi had
occurred in the preparation of the sections, but there is little doubt from the
swollen and dilated appearance of the majority of these processes that over¬
distension of the limiting membrane was sufficient to cause rupture during
life. It is evident, therefore, that myriads of Leishmania parasites must have
been liberated into the intestinal contents during the course of the disease,
and it is interesting to conjecture as to the possibility of their survival in the
faeces.

The fact that the flagellate stage of the organism is incapable of living for
any length of time in cultures which have been contaminated by bacteria is
against the presumption of the continued viability of the parasite in faecal
material in this phase of its development. Is it possible that some hitherto
undescribed encysted form is developed in the faeces? The contaminative

6 Perry: Observations on the Occurrence of Leislimania

cycle of development of the various species of Hcrpetomoncis of insects, to
which attention has often been directed in this connexion, is a tempting
analogy. Again, if the parasite in some resistant form can withstand the
inimical nature of its surroundings in the fasces, have the possibilities of its
ingestion by some faecal-feeding insect been exhausted ?

Further research alone can decide whether the insect-borne or alimentary
theory will prove to he correct in defining the exact aetiology of the disease,

Fig. l.i

but the fact that, in at least some cases of kala-azar, there occurs an intense
elimination of parasites into the intestinal canal may stimulate renewed
research into every possible method of dissemination of infection through the
medium of infected faeces. In this connexion the summing up of Knowles [7]
on this aspect of the question maybe quoted: “This possibility (i.e., faecal
transmission) deserves, perhaps, more careful consideration than it has hitherto
received. In Assam, at least, the distribution and incidence of kala-azar is

1 For the loan of the blocks illustrating this paper the author is indebted to the Editor of the
Journal of the Royal Army Medical Corps.

Section of Tropical Diseases and Parasitology

closely associated with insanitary surroundings and an absence of all con-
servancy methods/’

In conclusion, I wish to emphasize the fact that I do not suggest that these
findings are of usual, or even of frequent occurrence, in the small intestine in
kala-azar. They appear to me, however, to be of sufficient interest and
importance to bring forward in the hope that, attention having been directed
to them, information may become available as to the extent to which they
occur in fatal cases of this infection.

Fig. 2. Fig. 3.

REFERENCES.

[1] Christophers, Kala-azar Bull., 1912, iii, p. 154. [2] Jemma and Di Christina, A'afa-

azar Bull., 1912, iii, p. 154. [3] Byam and Archibald, “Practice of Medicine in the Tropics,”

1922, ii, p. 1452. [4] Patton, Indian Journ. Med. Research , 192*2, ii, p. 496. [5] Adie, Indian

Journ. Med. Research , 1921, ii, p. 255. [6] WENYON, Troj). Dis. Bull., 1922, xix, p. 15.

[7j Knowles, Indian Journ. Med. Research , 1920, viii, p. 175. [8] Mackie, Indian Journ. Med.

Research , 1914, ii, p. 510.

Dr. Row (Bombay) said that Colonel Perry’s contribution was most important in
the study of the complex phenomena observed in leishmaniasis. A study of the illustra¬
tions and lantern slides which he had shown convinced one of the importance of a close
and co-ordinated study of pathological processes in viscera apparently healthy, even in
the absence of gross post-mortem changes in the organs. Apparently no regular or
routine examination of the small intestines which showed no obvious lesions (e.g.,
ulceration) had been yet made, and all the attention of workers had been directed to

Khalil: Gastrodiscoides hominis

the naked-eye and microscopic study of the ulcers found in the large bowel to which
Colonel Perry had drawn attention. It was only natural that, in the absence of
microscopic data of apparently healthy mucosa of the small intestines in kala-azar, no
record of the remarkable invasion of the villi with the Leishman-Donovan parasites
could be found in any of the memoirs on this subject. It seemed that in the light of
what Colonel Perry had shown them, it was essential to examine every tissue and
every organ even when these gave no suspicion of any pathological changes. The
difficulty of identifying anything resembling the Leishman-Donovan parasites in the
gut contents was only to be expected when one remembered how the parasite could
pass through morphological changes, beyond recognition, even in artificial cultures—a
fact which he (Dr. Row) had communicated before the Royal Society of Tropical Medicine
last month—and especially when one bore in mind the massive microbic proportion of
the gut content. There was the greater reason to Buspect cryptic forms of Leishmania in
the gut contents, and such forms, it was conceivable, might be taken up by insects and
disseminated in some way unknown; and, as Colonel Perry had so cautiously put it, only
future investigation would settle these points. With reference to the parasite being
found in the peripheral circulation to the extent of 45 per cent, according to Knowles,
he would state his own experience on this subject although he had not had the
opportunity of studying a very large number of cases. Out of twenty-five consecutive
cases he had obtained cent, per cent, positive results by adopting a slight manoeuvre
in the technique, which consisted in diluting the peripheral blood from a kala-azar
patient with a large volume of citrated saline solution and using the deposit of the
corpuscles for culture. This was done with the object of diluting the serum and
reducing to a minimum the destructive influences of any antibodies or other agencies
in the blood serum antagonistic to the flagellates of the scanty parasites, or parasites
weakened by the grip of the leucocytes in the blood. In any case it seemed that
more attention had been drawn to the presence of parasites in the blood and less to
the presence of the parasites in the intestinal contents; and Colonel Perry’s paper,
therefore, opened up a wide field for further investigation of the aetiologieal factors of
leishmaniasis, which up till then had eluded the observation of all workers.

A Description of Gastrodiscoides hominis from the Napu

Mouse Deer.

By M. Khalil, M.D., Ph.D.

(From the Department of Helminthology , London School of Tropical Medicine.)

While acting as Honorary Parasitologist to the Zoological Society of
London, I found a large number of living specimens of Gastrodiscoides hominis
in the caecum of the Napu mouse deer (“ Tragulus napu") that died in the
Zoological Gardens. The animal belonged to the Prince of Wales' collection
from the Malay States. In addition, the abundant material from man in the
Helminthological Department of the London School of Tropical Medicine was
available for comparison. Whole mounts and serial sections of specimens from
both collections were examined and compared.

Synonyms: Amphistomum hominis , Lewis and McConnell, 1876. Amphi -
stomum ( Gastrodiscus) hominis , Sonsino, 1895. Gastrodiscus (?) hominis ,
Fischoeder, 1902. Gastrodiscus hominis , Stephens, 1906. Gastrodiscoides
hominis , Leiper, 1913.

Section of Tropical Diseases and Parasitology

(I) Historical Keview.

The parasite was first discovered and described by Lewis and McConnell
[10] in 1876. They found it in the caecum of man. Their description of the
internal structure is inaccurate and incomplete. They claimed that the
parasite had one testis and one ovary. As Stephens suggested, it is probable
that Lewis and McConnell overlooked the presence of the relatively small
ovary and interpreted the posterior testis as an ovary.

Stephens (1906) redescribed the parasite. His material was also from man
in Assam. His description is brief and his figures are very diagrammatic.
He amplified the description of the parasite and corrected some of Lewis’s and
McConnell’s statements as to the internal anatomy.

The parasite was first placed in the genus Amphistoma , which has since
lapsed as a synonym. It was tentatively placed in the genus Gastrodiscus
(Leuckart, 1877) by Fischoeder in 1902. This was confirmed by Stephens
115] (1906). Leiper [8] re-examined the parasite in 1913 and created the
genus Gastrodiscoides for it. This genus has not been widely accepted, and
recently Clayton Lane [5] criticized some of the characters upon which the
genus Gastrodiscoides is based and retains the parasite in the genus Gastro¬
discus .

(II) External Characters.

(a) Colour .—Fresh specimens are reddish. The colour of preserved
material differs according to mode of preservation. Specimens fixed in
Schaudinn’s fluid are whitish. In formalin they have a dirty brown tinge.

(b) Size .—Living specimens vary a good deal in size; the body is very
contractile, and can be elongated to a length of 1 cm. The distinction between
the anterior elongated part of the body and the posterior discoidal part is ill-
defined. Specimens preserved in alcohol are shrunken in appearance and vary
in length. The length of specimens preserved in formalin varies between
5 mm. and 7 mm. When fixed in Schaudinn’s fluid, the specimens have
uniform shape, and are very constant in size, being 5 mm. in length. In the
following description measurements refer to specimens fixed by the last-
mentioned method.

(c) Form .—When preserved in Schaudinn’s fluid, the body is divided into
an anterior conical portion and a posterior discoidal portion, quite evident to
the naked eye. ( See figure, p. 10.) The anterior portion is about 2 mm. in length
and is flattened dorso-ventrally. The anterior extremity is bluntly rounded,
and the transverse diameter increases in width towards the junction with the
posterior discoidal portion. The anterior surface is flattened, and may be a
little concave. In the middle line, nearer the posterior than the anterior
extremity, protrudes the prominent genital papilla, distinctly visible to the
naked eye. This characteristic is constant in all specimens preserved in
Schaudinn’s fluid, although it is less marked in specimens preserved in for¬
malin. The dorsal surface is convex. The discoidal portion of the trematode
is practically circular, being a little elongated in the long axis of the body. The
ventral surface is deeply excavated with a thick overhanging rim, which
becomes less marked at the junction with the anterior conical portion. The
dorsal surface is very convex.

(d) Acetabulum .—The acetabulum is in the caudal portion of the body. Its
aperture is directed ventrally. It is 2 mm. in diameter. The aperture of the
acetabulum is 1’75 mm. in diameter. The cavity extends rather towards the

Khalil: Gastrodiscoides hominis .

head than caudally. The rim of the acetabulum is overlapped by the surround¬
ing tissue, but is separated from it by a deep narrow groove. The cavity of
the acetabulum is 1*42 mm. long and 0 5 mm. deep.

(e) Cuticle .—The cuticle is smooth and unprovided with spines. The
discoidal portion of the worm is devoid of papillae or pseudo-suckers, as seen in
Oastrodiscus .

I mm.

Gastrodiscoides hominis. Camera lucida tracing of parasite flattened, while living, with
two slides and fixed in 70 per cent, alcohol. Genital cone pressed to one side.

(Ill) Digestive Tract.

The oral aperture which pierces the cephalic extremity of the worm is
not provided with a sphincter. It leads directly into a muscular sucker. The
oral sucker is globular; length 0*42 mm., and breadth 0*35 mm. Its posterior
end is slightly constricted. The two pharyngeal pouches join the pharynx
at this point. Each pharyngeal pouch is pear-shaped; length 0*5 mm.,
diameter 0*25 mm. The pharynx is elongated, and pursues a rather tortuous
course; length 1 mm., diameter 0*25 mm. It ends posteriorly in a strong
pharyngeal bulb. The pharyngeal bulb connects the pharynx with the two
intestinal caeca. It is globular, with a diameter of 0 45 mm. The two in¬
testinal caeca curve gracefully, caudally, around the anterior testis, and then
follow a straight course to their termination, diverging gradually from one

Section of Tropical Diseases and Parasitology 11

another as they are followed to their termination. The termination of each
caecum is slightly bent inwards, and lies on a plane slightly cephalad of the
acetabulum. The length of the caeca is 2*75 mm. Their termination is
2*5 mm. apart. In their caudal half the caBca are surrounded by the
vitellaria.

(IV) The Genital System.

The male and the female genital organs, with the exception of the vitelline
glands, lie mainly between the intestinal caeca with the testes slightly over¬
lapping the gut.

(a) Male Organs .—There are two large slightly lobulated testes which lie
close to the bifurcation of the gut. The testes are strictly diagonal, but their
zones and fields overlap to a great extent. In longitudinal serial section the
central portion of the worm will show a considerable portion of one testis
lying directly in front of the other. This appearance probably led both
Stephens and Leiper to assume that such was the position of the testes.
The anterior testis is faintly marked into four lobules. It is 0*75 mm. in
average diameter* It is situated at the junction of the two intestinal caeca
with its main portion to the left of the sagittal plane. It slightly overlaps
the intestinal caeca in the neighbourhood. The posterior testis is faintly
marked into five lobules. Its average diameter is 0*75 mm. Its bulb lies-
to the right of the sagittal plane, overlapping the right intestinal caecum. Its
main portion is situate posteriorly to the anterior testis. The narrow space
between the two testes is about 0*2 mm. in width. In sections, owing to the
contraction and shrinkage of the worm, the testes may actually be seen in
contact with one another. Both testes lie nearer the ventral than the dorsal
surface* They are entirely within the discoidal portion of the worm. From
the dorsal aspect of each testis the corresponding vas efferens proceeds, both
uniting to form the common vas. The vas inclines towards the ventral surface.
It i 9 dilated in part of its course to form apparently a seminal vesicle. There
is no evidence of the presence of cirrus pouch with pars prostatica. The duct
opens on the summit of the genital papillae just below the opening of the
female duct.

(b) Female Organs .—The ovary lies in about the middle line of the body
somewhat nearer the ventral than the dorsal surface. It is a little cephalad
of the acetabulum and posterior to both testes. It is oval, with diameter about
0*25 mm. The shell gland is smaller than the ovary and lies to its right
postero-laterally. Its diameter is 0*18 mm. The oviduct begins in the
narrow angle between the ovary and the shell gland. There is a large recep-
taculum seminis cephalad of the ovary. The uterus lies mainly near the
dorsal surface, curving from side to side but restricted to a narrow zone
about the sagittal plane of the body. A coil passes between the two testes on
their dorsal aspect. The uterus is compactly filled with eggs, and opens on
the top of the genital papilla caudad of the opening of the male duct. Laurer’s
canal commences dorsally by the ovary and passes directly caudad, opening on
the dorsal surface by the body 0*17 mm. caudad of the ovary. The vitelline
glands consist of two fairly compact masses each surrounding the corre¬
sponding intestinal caecum. In pressed fresh specimens, the vitelline glands
are confined to the posterior discoidal portion of the body. Their cephalad
limit lies in the region of the anterior testis about its centre. Caudally the
glands stretch to the level of the centre of the acetabulum. The outer border
of the glands lies parallel to the lateral margin of the body and 0*5 mm. away

Khalil: Gastrodiscoides hominis

from it. The inner border is straight, crossing the intestinal cseca about their
middle. Both these borders meet cephalad at a narrow apex. The caudal
limit of the glands lies parallel to the border of the acetabulum and about
0'2 mm. from it. From each group of glands on either side a duct passes
towards the middle line just caudad of the ovary. The two ducts meet in the
angle between the ovary and shell gland. The ova are passed in the single
•cell stage with a large amount of vitelline material. The shell is fairly thick
with a double outline. The ova are 152 p in length, with a maximum diameter
of 60 /*. The eggs are distinctly operculate.

(c) The Genital Cone .—The papilla on which the genital tubes open is a
very striking feature of the parasite and is seen distinctly with the naked eye.
The papilla is broadly blunt at its apex where box-ducts open. In section
the cuticle on the papilla is occasionally corrugated into folds which appear as
a knob-like structure. In whole specimens cleared, the papilla is always seen to
be smooth. The papilla projects about 0'2 mm. above the surface.

(V) Excretory System.

The elongated excretory vesicle lies wholly dorsal to the acetabulum. The
excretory duct opens on the surface in the middle line at the caudal pole.

(VI) Habitat.

Caecum and large intestine.

(VII) Hosts.

The parasite was first found in man and although from the beginning an
herbivorous host was suspected none was reported till 1913, w'hen Brau et L.
Bruyant [2] found it in 5 per cent, of pigs in Cochin-China. The parasite in
the pig was determined by these authors as identical with that found in man.
They found in certain localities very small forms not exceeding 3 mm. in
length ; probably these were immature forms although the authors do not
allude to the state of their sexual maturity. Professor Leiper has drawn my
attention to the fact that in his paper (Leiper, 1913) [8], he erroneously
attributed the recording of this parasite in pigs to Mathis and Leger. As this
mistake has been copied into some text-books he has asked me to make the
correction in this communication.

The Napu mouse deer is thus a new herbivorous host. It is difficult to
decide which is the normal host of the parasite, but it is probable that man
becomes infected more from the pig through the intermediary of a yet
unknown molluscan intermediary host.

Manson-Bahr [13] suspects that species of the genera Bullinus , Planorbis
and Physa may be intermediate hosts. He bases his opinion on analogy with
members of the genus Gastrodiscus. In this he overlooks the fact that para¬
sites belonging to different species of the same genus may have snail inter¬
mediate hosts belonging to widely different genera or even different families.
This is quite evident from our knowledge of the intermediate host of Schisto -
somum haematobium, Schistosomum mansoni , and Schistosomum japonicum , for
the snails which transmit these parasites are very widely different from each
other. This statement of Manson-Bahr is to be regretted as it may lead some
observers to confine their search to these particular genera of snails. In the

Section of Tropical Diseases and Parasitology

search for the intermediate host of Gastrodiscoides hominis , all local snails must
be taken into consideration, and it is only local distribution of snails in relation
to the prevalence of the infection either of man or animals that will afford any
real help.

(VIII) Geographical Distribution.

The parasite has a very limited range. It is confined to the Malay States,
Assam, Cochin-China, and India — practically south-eastern Asia. Cases
reported from other parts of the world, e.g., British Guiana, are traced to
immigrants from the endemic area.

(IX) Pathogenesis.

Very little is known regarding the effect of this parasite on man or
animals. More observations are needed.

(X) Treatment.

The parasites are easily expelled by thymol given in the same manner as
for hookworm.

REMARKS ON the genus Gastrodiscoides .

In 1913 Leiper [8] proposed the genus Gastrodiscoides with the type
species hominis and thus excluded this parasite from the genus Gastrodiscus
in which it was formerly incorporated. The main points on which he based
his new genus were: (1) tuberculated genital cone ; (2) position of genital
orifice; (3) smooth ventral disc; (4) testes in “ tandem ” position.

Stephens in “ The Animal Parasites of Man,” refers the parasite to the
genus Gastrodiscus , although he alludes to the genus Gastrodiscoides in a foot¬
note. Manson-Bahr [13] in Manson's “ Tropical Diseases ” (seventh edition,
1921) accepts the genus Gastrodiscoides , while Castellani and Chalmers [4] still
adhere to the genus Gastrodiscus . In these three text-books the respective
authors do not discuss fully the reasons which led them to adopt the particular
attitude they have taken up.

In 1922 at a laboratory meeting of the Royal Society of Tropical Medicine
and Hygiene, Clayton Lane [5] showed sections of a type specimen of Amphi-
stomum hominis in which he discovered that the genital ducts open into “ a
genital pro-atrium in the shape of a saucer surrounded by a tuberculated
area.” This was supposed to dispose of one of the chief characters on which
Leiper based his genus. I have examined fifty specimens with the aid of a
lower power of the microscope and in every one I was able to see distinctly
a protruding genital cone. The specimens were fixed in Schaudinn’s fluid and
preserved in 70 per cent, alcohol. In serial longitudinal section the apex of
the protruding genital cone is found to be flattened and occasionally having a
slight depression in the centre. An exaggeration of that appearanqe owing to
different methods of preservation apparently explains Lane's “ pseudo-sucker ”
but it may be noted that it is always at the top of the protruding genital
papilla. Thus I think that Leiper is justified in taking this character as one
of his differentiating points for this genus.

The question of importance is rather—Do the differences between the
species Gastrodiscoides hominis and Gastrodiscus aegyptiacus suffice to
place them in two different genera or no ? My own opinion is that the genus

F- Tr lb

Khalil: Gastrodiscoides hominis

Gastrodiscoides is justified by the absence of pseudo-suckers from the ventral
aspect of the discoidal portion and the presence of the genital pore on the
elongated cephalic position of the body, but that Leiper’s definition of the
genus ought to be modified as regards relative position of the testes. These
are not “tandem ” but are definitely diagonal.

BIBLIOGRAPHY AND REFERENCES.

[1] Blanchard, R., “Traits de Zoologie MSdicale,” 1888, i, Fas. 3, pp. 632-636, figs. 327-329.
[2] Brau et Bruyant, “Presence du Gastrodiscus hominis chez l'homme en Cochinchme,” Bull.
Soc. Path. Exot ., 1911, i, p. 488; “ Quelques notes sur les helminthes du pore eu Cochinchine,”
Bull. Soc. Path. Exot., 1913, vi, pp. 41-43. [3] Braun, M., “Die tierischen Parasiten des

Menscben,” Eine Handbuch f. Studireude und Aerzte, 2nd ed., 1895, pp. 137-138, fig. 52.

[4] Castellani and Chalmers, “ Manual of Tropical Medicine,” 3rd ed., 1919. p. 563.

[5] Clayton Lane, “Practical Demonstration and Notes,” Trans. Boy. Soc. Trop. Med. atui

Hyg ., 1922, xvi, p. 22. [6] Fischoeder, F., “ Die Paramphistomiden der Siiugetiere,” Zool.

Aw*.,Leipz., 1901, p. 374, and Zool. Jahrb., Jena, 1903, p. 496. [7] Giles, G. M., “ A Report of an
Investigation into the Causes of the Disease known in Assam as Kala-azar and Beri-beri,”
Shillong, 1890, p. 125. [8] Leiper, R. T., “ Observations on certain Helminths of Man,” Trams.

Soc. Trap. Med. and Hyg., 1913, pp. 292-295. [9] Leuckart, R., “Die Parasiten des

Menschen,” 2nd Aufl., 1889,, i, pp. 450-464. [10] Lewis and McConnell, J. F., “ Amphistoma

hominis n. sp., a new Parasite affecting Man,” Proc. Asiatic Soc. of Bengal, 1876, p. 182, pi. iii.
[11] Looss, A., “Ueber neue und Jiekannte Trematoden aus Seeschildkroten nebst Erbrterungen
zur Systematik und Nomenclatur,” Zool. Jahrb., Jena, Abt. 2, Syst. v, 16 (3-6), November,
1907, p. 746. [12] Looss, A., “On some Parasites in the Museum of the School of Tropical

Medicine, Liverpool,” Ann. of Trop. Med. and Parasit., 1907, i. No. 1, pp. 123-154. [13] Manson-
Bahr, P., Malison’s “Tropical Diseases,” 1921, 7th ed., Cassell and Co., Ltd., London, p. 804.
[14] Shipley, A. E., “ Cladorchis watsoni: A Human Parasite from Africa,” Thompson Yates
and Johnston Laboratories Report, 1905, vi, Part I, pp. 3-9. [15] Stephens, J. W. W., “Note

on the Anatomy of Gastrodiscus hominis (Lewis and McConnell),” Thompson Yates and Johnstcm
Laboratories Reports, n.s., 1906, vii (1), February, pp. 7-12, figs. 1-4. [16] Ward, H. B.,

“ Precision in the Determination of Human Parasites,” J. Am. M. Asa., Chicago, 1903, xli, p. 704.

Section of (Tropical Diseases ant> parasitology

President — Sir Leonard Rogers, C.I.E., M.D., F.R.S.,. I.M.S.

Framboesia: History of its Introduction into India; with
Personal Observations of over 200 Initial Lesions.

By Arthur Powell, M.B.

The history of yaws in India taken alone seems to me sufficient to prove
that syphilis and yaws are two distinct diseases.

Syphilis has existed in India for centuries and is specially prevalent among
the coolies recruited from distant parts of India to the tea estates of Assam.
In the estates under my care from 7 to 10 per cent, of the population were
syphilitic.

Although prevalent in the Dutch Indies, Malaya and Ceylon, no case of
yaws had been observed among the three hundred million inhabitants of
British India till in December, 1899, after a residence of one and a half years
in Assam, I met my first two cases. From these two the disease spread by
direct contact till in ten years I personally observed and treated in a narrow
strip of land 22 miles long, by 4 wide, 653 cases in a population of about 6,000.

In 1887 a coolie woman came from Ceylon with three daughters, the
youngest being infected with yaws. The other two girls in turn became
infected, and were constant visitors to the lines in which cases were first seen
by me. These four women called the disease “ faranghi” while all the other
coolies called it “ The New Disease.’*

I left Assam in 1900 and lived in Bombay for nineteen years. During that
time I travelled much in the country, where children run about naked up to
the age of 8 or 9—the period at which yaws is most prevalent. The working
classes are so scantily clad that an eruption like yaws can scarcely fail to be
noticed by the most casual observer. Yet in all that time I saw only one case
of yaws—a pilgrim from Sumatra on his way to Mecca. I had a large venereal
. practice, and all kinds of unsightly skin diseases were brought to me by the
police in my capacity as Inspector of Lepers, but no other case suggestive of
yaws was ever seen.

The map (fig. 2) shows the infected gardens under my care. The infected
coolie from Ceylon lived at Konapara. The first cases seen by me were at
Digabar, 2 miles away, where thirty cases arose in seven families before a
case arose elsewhere. By 1901, there were 256 cases on this garden. In
1891 a woman with a yaws-infected child went from Digabar to Dankargul,
about 17 miles distant, where fifty-five of a population of about 200 became
infected. In 1893 a family went from Dankargul to Nuncherra, 2 miles

Je—Tr 1 [February 5, 1923.

Powell: Framboesia

distant. Within a fortnight one of the children was found to have yaws.
By 1899 of the 400 inhabitants sixty-five had contracted yaws.

In 1896 Mulagul garden which used the same bazaar as Dankargul, less
than half a mile distant, became infected. In four years there were forty-
seven cases in a population of 350.

A woman from Digabar came to Konapara in 1893. A week later Case I,
her son, aged 4, was found to have yaws. He died of malaria a month later.
No other case arose here till January, 1897, when Case II, a woman who
frequently visited a paramour in Digabar, was found to have a large primary
yaw on a gummatous ulcer of the right leg which was soon followed by a
general eruption. Case III, her baby, aged 2, had been vaccinated on
December 3, 1896. There was a primary yaw on the vaccine scar and a

general eruption followed in January. In five months* time all six members
of her household were infected. Of 400 inhabitants, by the year 1900 seventy-
two had yaws. Magenta, almost contiguous with Konapara, became infected
in 1897. Fifty-three cases arose here.

In 1894 a woman from Digabar brought to Craigpark hospital Cases III
and Y, two children with a general eruption of yaws. I advised the manager
to send her back, but she ran off. Four years later I recognized her at Barkhola
where Dr. Chartres showed me some cases of yaws.

Early in 1896 the disease spread to Kauakauri, the nearest village to
Digabar. From there it quickly extended to the almost contiguous garden,
Hilara.

Case VI. —A lad, aged 16, introduced the disease into the village, not garden, of
Kalaincherra. In January, 1897, he showed me a granuloma in size and appearance

Section of Tropical Diseases and Parasitology

very like a raspberry, on the palmar surface of the web between the left thumb and
index finger, which he said had been there for three weeks. On the Durga holiday he
had gone to Digabar and during a drunken spree had fallen, cutting the site of this
primary yaw. If his dates were correct, the incubation period was thirty-two days.
In February he had a general eruption. Cases VII and VIII, his two sisters, had
been vaccinated on January 4,1897; on February 2,1897, the younger had a granuloma
the size of a pea on the vaccine scar; the elder had a papule the size of a No. 4 shot,
which later became large and fungating. General eruptions followed in both.

Seventeen other cases occurred in this village. In four the initial lesion
appeared on the site of ankylostome vesicles on the feet.

Haffkine, who had seen many of my cases, recognized the disease in 1895
in Chargola tea estate, in coolies who were probably deserters from my district.

In 1897 Dr. Chartres showed me some cases at Naraincherra and at
Barkhola where I identified the mother of one case as a coolie from Digabar,
15 miles distant.

In 1898, Hare [14], who had seen many of my cases, met three cases of
yaws in Upper Assam, to which a railway had recently been opened.

In 1900 Sir Walter Buchanan wrote me that he had admitted to Bhagalpur
Jail a prisoner suffering from yaws from an Assam tea estate. The prisoner
would not say from what garden he came.

In 1906 Powell Connor [7] reported cases to the south-west comer of

Powell: Frambcesia

Manipur, the comer nearest to my district. I may point out on the map
(fig. 2) the little Manipuri settlement between the three most infected gardens.
Many hundreds of Manipuris came to me for surgical treatment from Manipur
and lodged in these houses while waiting for admission to hospital.

I think all the above cases may fairly be looked on as originating from the
Digabar focus.

Hirsch [17] says the sole reference to yaws in India previous to 1881 was
made by Huillet [18]. Reference to the original “ Hygiene de PondichSry ”
shows that personally Huillet saw none, but some years before 1861, the late
Monsieur Beaujean saw “ une sorte de framboesia, petites taches pointill6es,
larges comme une pi6ce d’un franc, ayant une teinte 16g6rement plus pftle que
celle de la peau environnante.” These were cured in a few days by the
application of a solution of mercury perchloride. This may have been tinea
versicolor, but all will agree that it was no sort of frambcesia.

In October, 1894, Maitland [ 23] reported two cases from Travancore, the
furthest possible point in Southern India from Digabar. These were probably
imported from the neighbouring island of Ceylon.

In December, 1894, Nolan [31] reported an epidemic in the Lower Chind-
win district of Burma. Although as the crow flies this is only 300 miles
from Digabar, I feel sure the two epidemics arose independently, as in those
days there were no roads or communication between the two districts.
Swamps, rivers, and especially the Lushai Hills inhabited by head-hunting
savages, intervened. In 1906 McCarthy [22] reported 431 cases in the Lower
Chindwin district.

The Englishman reported that several cases of yaws among coolies
returned from the West Indies had been landed in Calcutta in May, 1895.

In 1896 Pilgrim showed four cases of yaws, in coolie children returned
from Fiji, to the Calcutta Medical Society, none of whose members had ever
seen similar cases.

In 1904, Gouzien [11] reported cases in Pondicherry.

The Primary Lesion.

Results on 205 Breaches of Surface continually observed till Yaws ensued .

The primary sore of yaws is not likely to be seen often by physicians
practising in a large city. It is when a coolie has an extensive eruption that
he comes for treatment. I was in a singularly fortunate position for observing
the patients at, and even before, the appearance of the first lesion, as nearly all
my patients were indentured coolies or their children. On each garden the
coolies parade each morning at roll-call, when a native doctor is present to
examine and treat all suffering from illness. Whenever a case of yaws
appeared in a garden this doctor was ordered to register any ulcer, wound,
leechbite or other breach of surface on all uninfected coolies, which might
serve as a site of inoculation. Such breaches of surface were then reported
to me and observed from day to day to see if yaws would ensue.

I have now notes of the initial lesion in 205 cases and have lost the notes
of some hundreds of others. I will preface my observations by saying that
not in a single case have I seen a primary lesion even remotely resembling the
ulcers described by Numa Rat [37] or in the text-books of Byam and
Archibald [4], Manson-Bahr [24] or Castellani and Chalmers [5].

In forty-three cases the first sign of the disease was a general eruption in
from thirty-five to one hundred and twenty-one days, no change beyond

Section of Tropical Diseases and Parasitology 19

healing being observed of the breach of surface by which the Treponema was
presumed to have entered.

Case IX.—On December 11, 1896, a girl, aged 15, came to live in lines where there
were several yaws cases. She then had an ulcer on the right shin. This healed
normally by February 1, 1897. On March 4, 1897, she had a general eruption as a
first sign. Nothing suggestive of yaws was seen on the scar.

In seven of these forty-three cases, though no lesion could be seen at the
site of presumed inoculation, an ordinary fungating granuloma appeared at
a short distance proximal to it; others still more proximal followed in a centri¬
fugal direction till finally a general eruption developed.

Case X.—A man whose wife and four children were suffering from yaws, cut his left
index finger with a billhook; this healed in about ten days. On the forty-second day a
small raised papule was noticed on the flexure of the left wrist. This grew into a
fungating granuloma. A week later three began in front of the elbow: about the end
of the second month there were five granulomata about the left shoulder, two over the
left scapula. The eruption then became general and copious.

Case XI.—A boy, aged 7, while bathing, cut the sole of his left foot on a broken
bottle. The wound healed with some suppuration in three weeks. A week later three
yaws appeared on the inner side of the left ankle : then two below the knee: two months
later the eruption was general. No yaw was ever seen on the sole.

Case XII.—A child, aged 8, whose two brothers had yaws, contracted itch on
both hands and wrists, where there were many large pustules. This was promptly treated
wdth sulphur. No yaw appeared on either hand or wrist, but a fungating granuloma
developed four weeks later over the middle of the left radius : a week later four or five
yaws appeared on the inner aspect of the elbow (a frequent site for the granulomata).
The whole of the upper arm was dotted with yaws by the end of a month. Later
the eruption became general. It is possible there may have been an itch burrow
at the site of the initial yaw, but none had been observed or noted by me or by my
assistants.

In 162 of these cases a raised fungating button, identical in all respects,
perhaps with the exception of size, with those of the secondary eruption,
appeared at the site of the presumed inoculation after an interval of from
seventeen to sixty-eight days. In at least eight of these cases the secondary
eruption appeared almost simultaneously.

A fungating granulomatous button takes some time to develop. If the
breach of surface by which the Treponema entered has skinned over, the
“ baby ” granuloma will be covered by cuticle and appear as a papule or
small nodule. If the ulcer be still unhealed the first indication of yaws will
be a raw granulation like a sentinel of “ proud flesh.” If the original wound is
healing under a scab, removal of this will show the raised granuloma. I have
never seen an initial yaw assume the annular form.

You will understand that when, without qualification, I use the term
“button,” “granuloma,” or “yaw,” with reference to the initial lesion, I
mean a fungating papillo-granuloma identical with those of the secondary
eruptions, and I shall not waste time by saying it began as a papule, or that it
was small before it was large.

The crust covering the granuloma is often characteristic. It is at first
tough, thin and strong, its outer surface dry, yellowish or greyish, and at first
smooth, resembling the bit of parchment pharmacists tie over the cork and
neck of a bottle (fig. 16, p. 37). Like this parchment it is firmly attached at its
periphery and difficult to remove. Yet on removing the periphery from the skin

Powell: Framboesia

the crust is found to have little attachment to the surface of the granuloma.
Usually there is little secretion from the raspberry-like surface, but occasionally
as much as a drop of thin, whitish, sticky secretion is found under the crust.
In situations like the palms, axillae and perinaeum, where skin is opposed to
skin, there is often no crust. When the crust is removed from an actively
growing yaw on an exposed position, a new crust generally forms. In other
cases when the crust is removed or falls off, the granuloma may become of the
mummifying type ; it becomes dry, its large papillaB tend to separate and look
warty (see fig. 12, p. 27).

In other cases the secretion from the underlying yaw thickens and dries on
the under surface of the crust: or if the latter has been cracked or partly
detached by scratching or friction, on both sides. In this way a more or less
rupia-like scab may result, but on its removal a granuloma is exposed, more or less
raised above the skin (fig. 14, p. 35). A rupial ulcer was never seen. When the
yaw heals there is no scar left unless the granuloma has been subjected to trauma
or caustic applications. If the patient's skin is darkly pigmented, a dark
stain is left which may last for a year or two. The dark colour is explained
by the great proliferation of the interpapillary layers which manufacture
pigment in the dark-skinned races; when this hyperkeratosis subsides in the
course of healing, a superabundance of pigment is left behind and takes a long
time to become absorbed. If the patient be of light complexion no excess of
pigment is formed, and the remaining “ tache ” is pale. If the granuloma has
been subjected to caustics, scraping or other trauma, there may be a white scar
due to the destruction of tissue. Some authors say that the primary yaw is
distinguished from the secondary eruption by its white scar. This is some¬
times true, but the scar is due to the ulceration which allowed the implantation
of the Treponema , not to the granuloma set up by the Treponema. If the site
of inoculation has been a puncture or wound that healed without much
suppuration, the site of the initial yaw after healing is pigmented just like that
of the secondary eruption.

Case XIII.—This woman slipped and fell, smashing an earthen jar she was carry¬
ing under her right arm. A fragment cut the inner surface of the arm. The primary
granuloma is in all respects like that of a secondary eruption (fig. 3).

Case XIV.—Photograph (fig. 4) is that of a woman who fell backward on a newly
pruned tea-bush. A chisel-like branch stabbed her in the left loin. This wound had
just healed when on the twenty-fourth day a yaw appeared on the scar. A secondary
eruption followed in about six weeks. You will see very little difference between
the primary yaw and the half dozen large secondary yaws. Note the papules or
u baby ” yaws on the inner aspect of the right elbow. These grew into yaws
resembling the primary.

Case XV.—A boy, aged 10, was bitten by a leech on the left calf, January 3, 1897.
This bite became inflamed and irritable. The boy scratched it repeatedly till a small
ulcer resulted. January 31, 1897 : A papule was evident, which increased and became
a large fungating button. A general eruption of smaller granulomata followed in May.
In June, 1897, Mr. G. Darby made a life-size sketch of the initial granuloma, which
was then 28 mm. in diameter (fig. 5). Later it reached a diameter of 4 cm. The
secondary granulomata for the most part became annular.

Case XVI.—A villager came to a cock-fight at Konapara. A cock spurred him on
the right calf. Seven weeks later he showed me on the scar of the wound a primary
yaw, almost an exact copy of Case XV.

Case XVII.—This woman, while priming a tea-bush, cut her right index finger
(December 27, 1897). Thirty days later the cut had healed, but a fungating yaw was

Section of Tropical Diseases and Parasitology

seen on the site of the scar. Photograph (fig. 6) was taken on the fifty-sixth day, when
the commencement of the secondary eruption can be seen as a papule on the flexure of
the left elbow. On April 4, 1899, she gave birth to a healthy boy.

Case XVIII.—Her husband tripped and cut his right shin on a sheet of corrugated
iron, April 2, 1898. The wound suppurated, and at the end of the month was the size
of a halfpenny, its lower half being covered with very tall granulations. By June l,the
whole wound was covered by a cauliflower-like granuloma overlapping the healthy skin
“ like the top of a champagne cork.” A secondary eruption appeared in July. When
last seen, January, 1900, the secondary eruption had healed, but the primary granuloma
persisted as a rather dry, warty growth.

Fig. 3.—Primary yaw.

Case XIX.—A woman, all of w’hose three children were suffering from yaws, was
wounded on the left side of the neck by some falling debris during an earthquake on
June 6, 1897. The wound was in a position likely to be touched by the children’s
arms, on all of which there were many granulomata. On June 28, 1897, she was
admitted for “ acute rheumatism.” This was, of course, the initial fever of yaws. I
first saw her on July 2, 1897, and observed a small papule on the healed wound. This
had grown into a circular granuloma 2 cm. in diameter, 8 mm. above the skin surface
in September, 1897, when I excised it as a typical initial lesion, and sent it to Sir
Jonathan Hutchinson. A general eruption broke out on July 23, 1897. On
March 23, 1899, she was delivered of a healthy child, which remained so till last
seen, February 1, 1900. The mother still had a few yaw r s on the back and thighs.

Powell: Frambaisia

Case XX.—This lad had herpes of the second left intercostal nerve. You can see the
pale scars running down the course of the intercosto-humeral nerve, as far as the wrist.
Later a yaw developed on the scar of a vesicle on the forearm. In photograph (fig. 7)
some papules are seen developing on the chin and cheek. A general eruption ensued.
Two years later all the granulomata had disappeared, their sites being indicated by
dark pigmented patches—a striking contrast to the white scars of the herpes.

Case XXI.—A woman, aged 27, two of whose children had yaws, had a whitlow of
the left index finger incised by a hospital assistant on July 14, 1895. Photograph
(fig. 8) shows the primary lesion of yaws on September 15, 1895. A general eruption
did not appear till about October 15, 1895.

Fig. 4.—Primary yaw on left loin.

Case XXII.—A girl, aged 5, ran a thorn into her left palm. Her father, who is
shown with an eruption of yaws, holding her hand, extracted the thorn with his
fingers. The photograph (fig. 9) was taken on the twenty-third day, when a papule had
formed, too small to be well shown. In time it became a raspberry-like yaw, and a
general eruption followed six weeks later.

In several of these cases the primary yaw became very much larger than
any of the secondary yaws. In most cases it lasted as long as the secondary erup¬
tion and in not a few it was the last to heal. My best photographs of such
yaws have faded, but Henggeler’s [16] Plate VIII, shows a primary yaw 3 in. in
diameter, very similar to cases I have seen. His Plate VII shows another on
the chin. His Plate III one near the left ankle.

Section of Tropical Diseases and Parasitology

In a few cases the primary yaw receded after a few days, but returned,
perhaps simultaneously with the general eruption.

The Satellite Type .—A primary yaw may appear and enlarge. A ring of

Fig. 5 .—Primary yaw

Fig. 6.—Primary

satellites may form round this. The little constellation may possibly be the
only sign, but as a rule it is succeeded by a general eruption.

Case XXIII.—A girl, aged 6, fell cutting her right eyebrow on a brass lotah. /The
primary yaw appeared thirty-two days later; within a fortnight it was surrounded by

Powell: Fr amber sia

a halo of twenty-four smaller yaws. A general eruption followed in about a month.
In photograph (fig. 10) several of the satellites have coalesced.

Case XXIV.—A girl, aged 16, had her name tattooed on the left forearm on March
18, 1898. On May 1, 1898 I found a yaw the size of a pea developed on what should

Fig. 7.—Primary yaw on scar of herpes.

Fig. 8.—Primary yaw.

have been a letter. Around this there were thirty-four papules scattered in a circle
nearly 8 in. in diameter. With two exceptions these were not on the tattooed lines
and were therefore not the result of external inoculation. In August the central
planet was as big as half a hazel nut, the satellites either from absorption or
coalescence were reduced in number to twenty-six and enlarged in size to diameters of
from"8 to 8 ram. There were about a dozen small yaws elsewhere on the body.

Section of Tropical Diseases and Parasitology

Case XXV.—A healthy female baby, whose mother and two brothers were then in
full eruption, showed a small pea-sized granuloma at the navel twenty-one days after
birth. This completely healed in about ten days after treatment with silver nitrate.
When the baby was eight weeks old, the granuloma recurred and increased till it was
the diameter of a threepenny-piece. By the end of the third month a halo of

Fig. 9.—Primary yaw on child’s palm : general eruption on her father.

Fig. 10.—Primary yaw on mother’s breast: satellite type on girl’s left brow.

twenty-two pea-sized granulomata formed with the navel as the centre. The whole
presented the appearance of a symmetrical target, 2 A in. in diameter. For over two
months no other general eruption appeared. This is the youngest case of yaws I
have seen.

Case XXVI.—A woman, while carrying her child slung on her back, fell backwards

Powell: Framboesia

and the child received a punctured wound on the left buttock from a stump of
a newly pruned bush. The mother who had a general eruption of yaws, repeatedly
wiped off the blood with her fingers. About four weeks later she noticed several
small yaws around the site of the wound. When photograph (fig. 11) was taken there
were twenty-four almost contiguous yaws on this site and only thirty-six elsewhere on
the body.

Case XXVII.—Fell on a cement floor and received a linear wound an inch long on
the right eyebrow. Photograph (fig. 12) shows nine almost confluent granulomata which
preceded the general eruption. They later became still larger and quite confluent,
surviving the general eruption by some months, as a warty growth off which individual

Fig. 11.—Primary yaw on mother’s breast: satellite primary yaw on child’s buttock.

dry papillae were often knocked. The ultimate scar was no larger than the original
wound.

If yaws be inoculated on a sloughing or very septic ulcer it is impossible to
say what the resulting picture will be. We had epidemics of tropical
phagedaena in the district, but fortunately few cases in the yaws-infected
gardens. In Looba, among 1,500 coolies, over 400 had phagedaena in the
year 1896.

I show photographs of a few of these ulcers, but it should be remembered
that they have no more to do with yaws than a cut throat or a shrapnel

Section of Tropical Diseases and Parasitology

wound ; either will serve as a site of inoculation. One cannot foretell what
will happen to such ulcers. They may heal slowly or they may slough till
tendon and bone necrose. I have even seen the limb fall off. If such a sore
be inoculated with yaws it would be absurd to describe the ultimate condition
—healing or gangrene,—as the “primary sore of yaws.”

Cases XXVIII and XXIX.—Two patients, each with an ulcer about the size of
a half-crown, stayed some nights in a house where children had yaws. In one the
phagedaenic sore, the presumed site of inoculation, was now a crater 7 in. by
4 in. exposing on its floor the necrosed tibia. Nothing like a granuloma was
seen on its margin, which was a smooth, indolent white line about 3 mm. wide. In
the second case the ulcer was healing, the peroneal tendons had sloughed, and a glazed,

FlG. 12.—Very old primary satellite, primary yaws on right brow. All the
eruption is dry, warty, uncovered by scabs.

indolent surface secreted much thin clear fluid. The margins were white and showed
no eminence or granuloma suggestive of yaws. Each case had a general eruption.

Case XXX.—Female, aged 22, with a stationary phagedaenic ulcer on the right
shin, became mistress of a yaws patient. Three months later a fungating tumour the
size of an acorn was present on the margin of the ulcer. The ulcer was otherwise
very much as it had been three months previously. Later a general eruption ensued.

In many cases if the site of inoculation be a chronic ulcer, the primary yaw
is very large, covering the whole surface of the ulcer and overhanging the
margin “ like the top of a champagne cork.” Such granulomata usually survive
all the general eruption.

Powell: Fratnbasia

Case XXXI.—Female, aged 50, had a large carbuncle on her backCwhich after much
sloughing left a large irregular ulcer. In April, 1896, a large fungating yaw appeared
on its margin; this became confluent with some smaller satellites on the edge of the
carbuncle. For two years a secondary eruption existed and then disappeared, but the
primary yaw was still present in January, 1900, as a kidney-shaped excrescence,
35 mm. by 20 mm., with dryish projecting papillae standing 12 mm. above the skin,
the whole looking like a split fig. The scar of the carbuncle was puckered and white.

Case XXXIL—The boy shown in photograph (fig. 13), came to the infected lines in
Konapara in 1897. He then had an ulcer, possibly phagedaenic, larger than a five-
shilling piece, on the ventral aspect of the left leg, a little above the ankle. The

Fig. 13.—General eruption : primary yaw above left ankle.

initial yaws lesion consisted of a partial ring of coalesced granulomata round the
upper, inner and lower circumference of the ulcer. At the end of three years, the
secondary eruption had healed, leaving pigment marks, but there was stUl a large
granuloma at the distal side of the ulcer. The scar of the ulcer was white. Note
the femoral bubo in this case and in No. 53—in both the result of septic absorption
from the ulcer.

The rapidity with which the disease can spread when appropriate sites for
inoculation are present is illustrated by a family of seven, who lived in one of
a group of huts near Digabar.

Section of Tropical Diseases and Parasitology 29

Case LIV, female, aged 5, and Case LV, female, aged l£, were vaccinated on
April 1, 1895. When first seen on May 15, 1895, both had large cauliflower-like yaws
on the vaccine scars. On June 15, 1895, both had a general eruption.

Case LVI.—Their father had a primary yaw the diameter of a threepenny-piece on
his scrotum where he had been bitten by a leech seven weeks earlier.

Case LVII, female, aged 10; Case LVII1, male, aged 7; Case LIX, female, aged 8,
all had extensive scabies. On July 13, 1895, the boy had a well-defined granuloma
above the left anterior superior iliac spine where several itch pustules had been chafed
by his waist-string. Case LVII had a pea-sized granuloma on the web between her
second and third left fingers. Case LIX had a fungating primary yaw in the left
gluteal fold. In all a secondary eruption followed. Six of the family of seven were
attacked within three and a half months.

Case LX.—The mother, aged 85, escaped till, in August, a carbuncle developed on
her nape. In September on the site of the carbuncle was an ulcer about the size of a
sixpence overhung by a granuloma which later became cauliflower-like and of the
diameter of a half-crown. Secondary eruptions followed and waned, but the primary
granuloma persisted for nearly three years, becoming in its later stage of a dry
papillomatous nature.

Case LXI.—Female, aged 10, sister of Case IX. A small abscess belo\y the left
patella burst about December 22, 1896. On February 14, 1897, a primary yaw the
size of a large pea had appeared, this grew to a large circular cauliflower-like growth
20 mm. in diameter. A general eruption followed, many yaws on the neck, chest and
abdomen becoming annular.

Case LXII.—Aged 16; the eldest sister, had an abrasion-contusion over the left
inner malleolus on February 2, 1897, which took about ten days to heal. On March 8,
1897, a papule was seen which grew to a granuloma about 15 mm. in diameter. In
May she had a copious general eruption. Both she and the patient in Case IX had
considerable fever and joint-ache both before the primary yaw and the general eruption^

Case LXIII.—Brother, aged 8, drove a splinter of wood under the nail of the left
middle finger on March 4,1897; a whitlow resulted and was incised on March 12, 1897.
On April 15, 1897, a fungating mass uncovered by any crust was overlapping the nail.
A general eruption was present on July 1, 1897. The younger sisters, Case LXIV,
aged 5, and Case LXV, aged 7, frequently evaded inspection, but both were found on
June 24, 1897, to have a general eruption of yaws, and an extensive eruption of
scabies. I was unable to identify a primary yaw in Case LXV. There wets a large
granuloma between the third and fourth left toes of Case LXIV, which the family said
preceded the others. In less than five months all six children were infected. The
mother was the only member of the family to escape.

Case LXVI.—Patient stubbed his left second toe on a splinter of wood which his
sister, Case II, extracted on March 3, 1897. A small granuloma was seen on this site
on April 14. Later it formed a large cap covering the tip of the toe. In June the
eruption was general.

Case LXVII.—His wife, aged 16, had itch, which was cured by sulphur by the
middle of April. On May 1, she had fever and pains in the joints, followed by a
general eruption, without any initial yaw.

Case LXVTII, female, aged 6, and Case LXIX, male, aged 8, children of Case II,
when first seen had scabies. In the case of the girl the first yaw appeared above the
right knee very little in advance of the general eruption. In that of the boy a
raspberry-like yaw appeared between the right fourth and fifth toes about five weeks
in advance of the general eruption.

In the next hut but one dwelt six people—

Case LXX.—A boy of 12, had a traumatic ulcer on the left inner malleolus, the size
of a half-crown. A month later the lower border of this ulcer became beaded with
raised granulomata which coalesced into three large yaws. In March 1897, a general
eruption developed.

Powell: Frambcesia

Case LXXI.—His brother, aged 9, got a thorn into his left sole on April 2, 1897,
which his brother (Case LXX) extracted: cellulitis followed. On May 1 he had a
painful swelling suggestive of an abscess; the cuticle over this ruptured and a
granulating base, looking like an ulcer, was exposed, surrounded by raised sodden
cuticle. A week later, after poulticing, this cuticle was peeled off, a typical raised yaw
being exposed. Three months later he had a copious general eruption.

Case LXXII.—Their baby brother in June showed a primary yaw* on the plantar
surface on the right great toe. No wound or puncture had been observed. About six
weeks later he had a general eruption, the lips, as is often the case in sucklings, being
severely affected. In October—

Case LXXIII.—His mother, showed a fungating granuloma at the base of the
[eft nipple. No previous lesion had been seen on this site, but probably a fissure had
been overlooked. In December she had a sparse general eruption. The only
inhabitant of the house to escape was the father.

In a house 20 yards away—

Cases LXXIV and LXXV, two boys, developed a general eruption without any
primary sore as far as I could observe. Their brother (Case LXXVI) fell, cutting his
knee; this healed slowly, but thirty-two days later a small yaw was observed on the
scar. Later it grew to the size of a big walnut. A general eruption followed.

Case LXXVII.—In the next house a female child, aged 5, had her right thigh
severely scratched by a thorn. Forty-five days later a primary yaw formed. In two
months a general eruption followed. Her parents and a brother were not affected.

Case LXXVIII.—Female, aged 14. Was first seen to have two granulomata on
the right arm, one on the left, which all arose simultaneously. Fresh yaws gradually
appeared till about thirty were present.

Case LXXIX.—Her elder sister three months later showed a typical yaw above the
anterior superior spine of the left ilium as a result of inoculation on a belt of pustulating
ringworm. In a house 50 yards away—

Case LXXX, a boy, aged 12, fell and wounded his right knee; this healed in a
fortnight. He eluded observation for six weeks, but on the fifty-second day a
granuloma 6 mm. in diameter, raised 3 mm. above the surface, wras noted. A general
eruption followed.

Four other dwellers in the hut escaped infection.

Case LXXXI.—Male, aged 10 months, was found to have a general eruption of
yaws. I could recognize no initial lesion nor did his relatives allege any.

Case LXXXII.—Patient’s mother got an abscess of the right breast. A sinus
resulted and this was not healed when a granuloma the size of a pea was seen,
uncovered by cuticle or scab. This rapidly enlarged and a general eruption was out a
month later.

Case LXXXIII.—Male, aged 16, son of previous case; a general eruption on the
arms and forearms was first seen September 1, 1897. No primary lesion was
recognizable, but the patient attributed the disease to scratching an eruption of prickly
heat.

In a line of six huts about 100 yards away—

Case LXXXIV.—Male, aged 8, was bitten by a leech on the left ankle on June 16,
1897. The bite inflamed and suppurated; before it healed on August 3, a granuloma
was observed on the site. A general eruption followed.

Case LXXXV.—Male, aged 12, his brother, while riding a buffalo, was accidentally
gored on the right flank. A large lacerated wound took two months to heal. A
primary yaw was first recognized on the granulating wound on the fifty-sixth day
after the accident.

Case LXXXVI.—Their grandmother had an initial yaw on the scar of a boil
between the scapulie.

Section of Tropical Diseases and Parasitology

Case LXXXV1I.—Their mother next had a general eruption in which neither she
nor I could recognize an initial yaw.

The Lymphatics.

A general enlargement of the glands was not noticeable in any of my cases
except in those complicated by recent syphilis. In cases like Nos. XXXII
and LIII where the initial yaw was implanted on an ulcer or septic wound
the corresponding glands were often enlarged, soft and painful.

Auto-inoculation.

In eleven cases I have taken the secretion from a papule or small granuloma
and used it as in the method of vaccination with cow-pox on the patient from
whom it was taken. In no case did any positive result occur.

In reviewing the literature on the subject of the primary lesion, we should
do well to ignore authors who have not personally seen what they describe
and to note that with exceptions like Castellani [5], Jeanselme [20],
Halberstaedter [13], Neisser [29], and Henggeler [16], few have special
knowledge of dermatology.

The description adopted by so many text-books, “ an ulcer with perpen¬
dicular edges and a granulating base/’ is so tautological as to bear evidence
that it did not originate with more than one observer. It means “an ulcer
with an ulcerating base,” as it is the function of all ulcers to granulate.
Possibly “ granulating ” was originally a misprint for “ granulomatous,” an
adjective which would convey some meaning.

Numa Eat [37] describes the initial lesion as : (l) “ An ulcer with perpen¬
dicular edges and a clean base.” (2) When the contagion has entered through
a granulating wound or an ulcer the primary lesion is a “ mass of granulated
tissue similar to that of the tubercles of the secondary stage.”

Numa Rat’s second, and according to my observation, correct description
is overlooked by most authors. The first was fastened on by Sir Jonathan
Hutchinson [19] and has been copied from text-book to text-book though it
is not based on Rat’s own observation, but on the hearsay evidence of his
unscientific negro patients. His cases “ illustrating the initial local lesion ”
are only two : “ Case I, Present Disease, Dermatitis of Sole.” The previous
history given by a negress patient supplies the description of the initial lesion
at least seventeen months previously, i.e., before Dr. Rat’s arrival in Dominica,
as stated in his preface. “ Case II, Present Disease, Dermatitis of the Sole,”
seen by Rat in July, 1890. The negro patient in September, 1881, nearly
nine years before Dr. Rat saw him, “noticed a small pimple on the edge of
the prepuce. On the top of this pimple a small water vesicle formed, and the
pimple ulcerated and formed an ulcer about the size of a florin. The ulcer was
red and clean.” Is it likely that a negro suffering from large cauliflower
excrescences would be dermatologist enough to recollect and describe a pimple
he had eight or nine years previously ?

In the Journal of Tropical Medicine , 1904, Rat [37] describes three initial
lesions all of the fungating type.

How many authors who quote Charlouis’s [6] “scientific” inoculations
have read his essay ? The primary sores which he caused were not the
result of treponemata only, but also of an “ X” quantity of variegated filth,
containing numerous pyogenic microbes. His modus operandi was to make a
pocket 1 cm. deep below the skin with a bistoury and then fill it with scab

Je—Te 2

Powell: Frambcesia

or blood expressed from an ulcerating yaw. He wrote in 1881, before the days
of antiseptics. You can easily imagine the result if you bury in the tissues a
chunk of scab which has possibly existed for months on the dirty skin of
a yaws patient. “ Gleich nach der Operation entstand Reaction, die sich als
eine ausbreitete Rothe mit lokaler Temperaturhohung zeichnete.” Pustules
with scabs resulted, on the removal of which painful ulcers were exposed;
on the floor of these were papillary outgrowths which became “ magnificent
fungating tumours.” One ulcer was 3 cm. deep. On this ultimately developed
a fungating tumour. The patients complained of painful swelling of the
neighbouring glands : the whole area was intensely painful from the ulcers to
the armpit, so that the weight of the shirt was unbearable. Rigors and fever
often accompanied the first symptoms. Many of these ulcers produced
fungating tumours, but those which did not left a whitish, thick, hard scar.
Is it necessary to point out that the fungating tumours and the secondary
eruptions were the result of the Treponema , and the ulcers, phlegmons,
rigors, &c., the result of the staphylococci and streptococci inoculated ? He
inoculated two Javans on one breast with yaw scab, on the other with
acne pus. Similar pustules resulted on both sides. It seems strange that
Charlouis's cases should be quoted as typical of the initial lesion of yaws when
transmitted naturally.

Charlouis was an honest observer. I confess I find Paulet’s [32] work
here and there suggestive of a page from De Rougemont or Munchaussen.
He induced more than 230 healthy negroes to have connexion with negresses
suffering from yaws. Thirty negroes showed him “une belle Eruption”
twenty-five to fifty days after connexion, their genital organs remaining intact.
More than 200 showed tubercles, some on the body, some on the genitals.

Jeanselme [20] describes the initial lesion as a papilloma, “ une sorte de
furoncle dur, couronn6 d’une croftte, sous laquelle se d6veloppe une ulceration
tenace dont les bourgeons exub&rants font dans la suite une saillie en forme de
choufleur. L’accident initial au niveau de la porte d’entr^e ne dififere pas des
elements qui apparaissent ulterieurement.”

Neisser [28], to whom I sent photographs and related my observations on
the initial lesion and failure to find tertiary signs, wrote on his return from the
Dutch Indies that his observations were identical with mine. He inoculated
two gibbons and five Macacus monkeys with yaws. In each case there
developed at the inoculated spot “on a slightly infiltrated base a moderately
thick, honey-yellow, very characteristic crust, on the removal of which an
easily bled, well-developed papilloma was exposed exactly like the framboesia
eruption in man.”

Halberstaedter [13] continued Neisser’s experiments with like results on
a total of eleven monkeys, two gibbons and an ourang-utan. On the ourang a
general eruption followed. Henggeler [16], an accurate observer who worked
on the plantations in Sumatra from 1896 to 1903, has written an excellent
article, beautifully illustrated. He says: “ On any little wound or epidermal
defect which is the source of entrance, the granulations begin to grow rapidly;
on the sore a fungose tumour of variable size, more or less raised above the
skin level, develops. The edge of the sore is never undermined, never clean
cut (scharf abfallend).’’ Though the growth was sometimes slightly infiltrated,
he has never found any hardness that would give the slightest resemblance
to a hard chancre. He is emphatic that he diligently searched for, but
never found, ( a ) any prodromal furfuraceous eruption, (6) any affection
of the mucosa, (o) any tertiary signs.

Section of Tropical Diseases and Parasitology

The careful observations of these distinguished investigators are worthy of
more attention than the crude experiments of Charlouis [6] and the childhood’s
recollections of Dr. Bat’s [37J illiterate negroes.

Of writers on tropical diseases generally, Scheube [41], whose practice
was in Japan, had little opportunity for personal observation. He follows
Charlouis’s [6] description of the primary sore with which I have already dealt.
He, then, on the authority of Bestion [2] describes a second form of initial
lesion as a vesicle increasing in size from a pin-head to a 20-centime piece;
around this new vesicles form and run together, while a papule develops from
th9 central vesicle. I have never seen anything like this.

In Bestion’s original paper [2] we find he describes a disease in the Gabon
called “ aboukou6” which has an incubation period of seven weeks, followed
by fever lasting a month. At the end of the second month severe pains in the
joints and bones are invariable. At the beginning of the fourth month a vesicle
the size of a pin-head appears and would scarcely be noticed except for its
itching which causes much scratching. At the end of ten to twelve days, the
vesicle has become a bulla the size of a 20-franc piece, surrounded by a halo
of new vesicles. An ulcer results, its base becomes irregular and ultimately
fungates. My view of this “ tandem ” disease is that the bullae are the terminal
stage of “ aboukou6” on which the initial yaw is inoculated in the process of
scratching.

Manson-Bahr [24] says that “ the primary lesion may appear as an
isolated papule or a bulla developing a few days later into an undermined
ulcer with a raw base.” Like Neisser [29] and Henggeler [16] I have never
seen anything in the least resembling this.

Castellani’s descriptions vary greatly [5]. In his and the late Dr. Chalmers’
book (p. 1542), it is said : “ If after some days the crust is removed the primary
sore will appear as an ulcer, not rarely of large dimensions, with clean cut
edges and a granulating fundus.” In “ The Practice of Medicine in the Tropics,”
edited by Byam and Archibald [4] (vol. ii, p. 1314), he says the “primary sore
appears in the form of an ulcer of varying and often considerable size with
a granulating surface.” These we may take as deference to the “ classic ”
description, for in his own experiments on monkeys the primary lesion was
a papule, and in his description of tropical phagedsena (p. 2185) he says
it often “ becomes infected with framboesia virus, takes a papillomatous
appearance and is followed by a general eruption of framboesia granulomata.”
His last description on page 1321 is perfect: “ The primary lesion does not
differ from the elements of the generalized granulomatous eruption.”

Halberstaedter [13] says, “Die Krankheit beginnt mit einer primaren
Effloreszenz an der Infektionsstelle, welche sich von den spateren Effloreszenzen
des Eruptionsstadiums kaum unterscheidet.” Brocq [3] says the initial
lesion appears “ sous la forme d’un bouton isol6, si^geant au point precis
o\ l’inoculation du virus s’est faite.” He adds that Henggeler describes the
initial lesion as occasionally a pustule. I can find no such statement in
Henggeler’s paper [16], but having said that the majority of the primary lesions
among his own bare-legged coolies naturally occur on the lower extremities
liable to leech-bites, cuts and scratches from jungle thorns and spear-grass,
he adds that they may occur on “ irgendeinen Epidermisdefekt. In anderen
Fallen entwickelt sich die Muttereffloreszenz aus einem 1 Eiterblaschen ’ (wie
in Falle III), oder aus einem kleinen Furunkel die wegen Jucken gekratzt und
dabei wohl infiziert worden waren.”—“ Owing to its itching the pustule gets
scratched and in this way inoculated.” Describing Case III he makes a

Powell: Frambcesia

similar statement. “ Die Infektion auf natiirlichem Wege setzt als Vorbe-
dingung das Bestehen eines Epidermisdefektes voraus, der in irgendeiner
Wunde am Fusse einem offenen Eiterblaschen (Fall III) einer Schrunde an
der Brust bestehen kann ” (p. 259).

Nicholls [30] thinks a general eruption is often the first sign, but “ should
there be any growth at the site of inoculation it differs in no essential
particular from the characteristic eruption/’

Nattan-Larrier and Levaditi [27] as the result of inoculating a chimpanzee
produced an “ulceration with a granular and budding base.” I may here
remark that many French authors use the word “ ulcere ” when describing the
secondary “ boutons/' For example, Kochas [38] speaks of “ Ulc£res saillies,
en bourrelet ” ; Paulet [32] of “ ulc^res, convexes, mam61onn6s.”

The General Eruption.

Though in all cases I have diligently searched for it, I have never found
a prodromal furfuraceous eruption.

In health the young coolie’s skin is usually well washed and oiled, giving
it a smooth and glossy appearance. Should he fall ill from any fever, malarial,
influenzal, framboesial or other—his skin loses its gloss. Planters often use
the language of the stable, saying a coolie must be ill “because his coat is
staring.” Tinea versicolor is widely prevalent. Jeanselme [20] says when
there is much fever in yaws the skin “devient rude et perd son lustre.”

Since the above was written Napier in the Indian Medical Gazette ,
December, 1922, contrasts the signs of kala-azar with those of other fevers.
He found “roughness of the skin” in 141 of 258 cases of kala-azar, and in
49 of 141 cases of other fevers. In a total of 382 cases of all fevers 190,
practically half, 4973 per cent., showed roughness of the skin.

Goodman [10], Henggeler [16], Neisser and his colleagues [28], Baermann
[l], and Halberstaedter [13], all say they have searched for, but never found,
any furfuraceous eruption.

As a rule in children there is little fever or joint-ache either at the
beginning of the initial sore or of the general eruption. In my adult cases the
proportion of those suffering from fever and osteocopic pain was smaller than
appears the rule according to text-books.

The general eruption begins in the form of small papules about the size of
pin-heads. Some of these may abort, the distended cuticle dropping off as a
small scale. This is the only approach to desquamation I have seen. The
papules which persist grow in height and breadth till we get the button-like
granulo-papilloma above described. The covering crusts are similar to those
of the primary lesion.

In many cases the granuloma assumes an annular form. In rare cases
this may be formed by the coalescence of smaller granulomata, but in the vast
majority it is caused by outgrowth from the periphery of a button while
healing takes place in the centre. In a few cases the crust covers the healed
centre as well as the ring of active granuloma.

An attack of continued high fever such as pneumonia, measles, small-pox
or remittent, often causes the eruption to recede temporarily, and in rare cases
to disappear altogether.

Case XXXVIII illustrates these last two points. In February, 1897, an
initial button appeared on the site of an abrasion in the left popliteal space.

Section of Tropical Diseases and Parasitology

Photograph (fig. 14) shows ths general eruption in an early stage in May.
Photograph (fig. 15) taken in December shows several of the yaws covered by
a rupia-like scab. 1 When these scabs fell off rings of granuloma enclosing
healthy skin remained, resembling those shown in photograph (fig. 17). In
January, 1898, he had left lobar pneumonia. Twelve days from its onset
the granulomata had completely disappeared, their sites being marked by
dark pigmented patches. In January, 1900, neither scarring nor pigmentation
remained, the skin being perfectly normal. In March, 1898, his wife gave
birth to a healthy daughter.

Fig. 14. —Early general eruption covered by thin parchment-like scabs.

In Case XXXIX an initial yaw appeared on an ulcer near the right ankle.
Photograph (fig. 15) shows the general eruption in the early button stage.
Photograph (fig. 16), taken ten weeks later, shows many of these buttons have
assumed the ring form, while many new papules are seen, especially on the
lower limbs.

Plantar Granulomata.

Photograph (fig. 18) shows a case of three granulomata on the sole looking
like ulcers. Some authors describe these as deep ulcers, forgetting the great
thickness of the plantar cuticle of those who walk barefoot. These yaws are

i Sir Jonathan Hutchinson, to whom I gave a copy of this photograph, reproduced it as a case
of rupial yaws in the New Sydenham Society’s Fasciculus 14 (fig. 11).

Powell: Fravibcesia

generally painful, so that the patient is constantly poulticing and fomenting
his feet, causing the cuticle to become sodden and swollen. In this example
I peeled off the cuticle, which over the heel was eleven millimetres thick. On
its removal the granuloma was seen to stand 7 mm. high above the cutis,
though at first its upper surface looked like the floor of an ulcer 4!mm. deep.

Tertiary Sequelae.

With the exception of three cases, in two of which yaws was contracted by
syphilitic patients, I have never seen any tertiary signs that could possibly be
attributed to yaws.

Fig. 15.—A later stage of fig. 14.

I ask you not to attach too much value to my evidence on this point as the
disease was new in my district, and with the exception of the family who
introduced it from Ceylon, no patient was under my observation more than
ten and a half years after inoculation.

Case XXXVII.—S., female, aged 28, had yaws when 18. An abortion was brought
on by a coolie midwife, who thrust a stick into the uterus. Severe septicaemia with
secondary abscesses set in, and all the larger joints became swollen. When last seen
in 1901 the patient was emaciated, almost crippled and unable to straighten the knees.
I attribute her condition to septictemia, but others may regard it as a sequel of yaws.

Section of Tropical Diseases and Parasitology

The other two cases I published in the Indian Medical Gazette , 1898, and
sent photographs and a fuller account of them to the late Sir Jonathan
Hutchinson. His errors in their description in the New Sydenham Society’s
“ Atlas ” and the Polyclinic necessitate my giving the history of the family in
detail:—

Case XXXIX.—B., male, aged 7, living in yaws-infected lines, cut his right knee on
July 2, 1894. A papillomatous button appeared on the scar by the end of the month
and a general eruption of yaws followed.

Fig. 16.—Early stage of ring-shape eruption, shown in fig. 17.

Case XL.—S., his sister, aged 16 months, was vaccinated on September 7, 1894.
In October a large fungating yaw was found on the vaccine scar. A general eruption
of yaws followed, and lasted eighteen months. The facies of this child, fig. 25, p. 18,
New Sydenham Society, Fasciculus 14, is typical of syphilis as diagnosed by Sir J.
Hutchinson. It shows the bridge of the nose sunken, the frontal bosses prominent
and scars at the angles of the mouth. Osteitis of the phalanges set in in November,
1897, when the child was aged 4 (fig. 16, New Sydenham Society, Fasciculus 18).

Case XLI.—R., aged 83, their mother, had an abscess of the breast incised,
December 5,1895. Early in February, 1896, an initial yaw appeared on the resulting sinus.
Photograph (fig. 10, p. 25) shows the initial lesion and secondary eruption. Another photo¬
graph shows a ring of yaws surrounding the mouth of the child. Simultaneously

Powell: Frambasia

with her child, S., osteitis of the phalanges set in in November, 1897. With mercurial
inunction and iodide of potash the osteitis in mother and child quickly subsided.

Case XLII.—A male child was born on April 15, 1898. Contracted scabies,
November, 1898. In January, 1899, a primary yaw appeared between the right index
and ring fingers. A general eruption followed and lasted till death from dysentery in
November, 1899.

F., daughter, aged 6. Case XXIII above, developed a primary yaw on a wound of
the eyebrow (fig. 10, p. 25).

Fig. 17.—Later stage of eruption shown in fig. lfi.

Case XLIII.—B., father, cut his left index, July 5, 1895 (photograph shown). In
twenty-two days a primary papule was noticed which grew into a large cauliflower mass
and a general eruption ensued.

Case XLIV.—J., female, aged 8, the remaining child contracted scabies. A
raspberry-like papilloma appeared in February, 1898, on the site of an itch pustule in
the left groin and in May was followed by a general eruption.

In his comments on these cases Sir Jonathan Hutchinson fell into many
errors, e.g., he attributes the case to Daniels, not to me. He says the child
was 18 months old when the photograph was taken. She was 4i years old. He

Section of Tropical Diseases and Parasitology 39

says the mother had suffered from yaws when pregnant of this child, whereas
the child was 2£ years old when she definitely inoculated her [mother with
yaws on a breast abscess. His contention is that yaws is only syphilis, and
that in these cases the granulomatous eruptions and the osteitis or dactylitis
are both symptoms of syphilis. We all agree with him that the child ha3
inherited syphilis. Father and mother therefore were certainly syphilitic, and
some if not all the sisters and brothers probably syphilitic. Is it possible to
have a more convincing proof than the history of this family that yaws and
syphilis are separate diseases conferring no mutual protection ?

Adopting Sir Jonathan’s diagnosis we have (l) a probably syphilitic noy,

Fig. 18.

aged 7, contracting a primary chancre of “ framboesoid syphilis ” on a wound
of the knee. (2) Inoculating his definitely syphilitic sister, aged 1$, with a
primary chancre on a vaccine sore, who in turn with her lips covered with
secondary eruption inoculates (3) her certainly syphilitic mother with a “chancre”
on the sinus of a breast abscess. (4) The mother bears another son who is
certainly the inheritor of syphilis, yet again, when 8 months old, develops a
primary “ chancre ” on an itch pustule between the fingers. (5) The father,
certainly syphilitic, cuts his finger and develops a second primary “ chancre ”
on his index finger. (6) A daughter, aged 6, probably the inheritress of syphilis,
contracts a chancre on a wound of the eyebrow. (7) Another daughter, born

Powell: Framboma

in 1890, and therefore most probably inheritress of syphilis, when aged 8,
contracts a primary chancre on an itch pustule. All seven develop a severe
granulo-papillomatous secondary eruption in their “ second attack of syphilis ”
and never show any other form of syphilide.

Cases in which syphilis was inoculated on patients while suffering from
yaws, were J., aged 40, and his wife, M., aged 30:—

Case XLV.—B., their eldest son, aged 10, was first seen by me in August, 1891,
when he had a general eruption of yaws said to be of three months’ standing. The
rest of the family was at once inspected for either yaws or a breach of surface likely to
become inoculated. I found:—

Case XLVI.—M., the mother had a cracked and pitted form of plantar hyperkeratosis.
About three weeks later an initial yaw was evident on a fissure in the flexure of the left
great toe. A general eruption ensued and lasted over two years.

Case XLVII.—B., aged 6, another son, had a small cut on the right calf which had
been present at least ten days. On September 15, 1891, he had an initial yaw on the
scar. A general eruption followed and lasted about a year.

Case XLYIII.—J., the father, was under treatment for itch. At the beginning of
October, 1891, a primary yaw was seen on the left wrist and a general eruption
followed. In June, 1892, he was found to have a hard chancre on the prepuce. In
September a maculo-papular syphilide appeared and co-existed with the yaws eruption
till his death in 1898 from dysentery, probably aggravated by mercurial poisoning at
the hands of a Kobiraj. As soon as J.’s chancre was seen, his wife was inspected at
intervals, till in December, 1892, a chancre was found on the left labium. Mercury was
given at once. Two months later the lymphatic glands generally were hard and
enlarged. In April, 1898, a papulo-squamous syphilide appeared and only lasted a few
weeks. The yaws eruption lasted till June, 1894.

Case XLIX.—Bh., aged 8, another son, was wounded by the fall of a heavy stone
on the right instep. Thirty-six days after the accident a primary granuloma appeared
on the scar. A general eruption of yaws followed. Only one child of this family
escaped infection with yaws.

Case LII.—P., a woman, aged 22, living in a house with her mother, sister, brother-
in-law, and two nephews who all had yaws, got a severe scratch on the right thigh in
May, 1898. An initial yaw developed on this site and a general eruption followed.
In October, 1898, I found a snail-track condition of the fauces, and later ulcers on the
tonsils. She then informed me she had for the past four months been mistress of
S., one of my own syces. On examination a healing chancre was found on the
fourchette. Her paramour had a hard chancre in January, 1897, and had been treated
by me for secondary syphilis and double iritis.

Of syphilitic cases who became infected with yaws I may mention Case II,
the woman cited above who reintroduced yaws to Konapara. The large
primary yaw appeared on a gummatous ulcer. Her two-year-old child, doubt¬
less the heir of syphilis, developed a primary yaw on a vaccine scar.

Case L.—S., female, aged 14, had a hare-lip operation in 1890, when I entered on
her case sheet, “ inherited syphilis. White streaks radiating from the angles of the
mouth, sunken nose, teeth irregular, but scarcely characteristic.” A gumma broke
down on her shin in July, 1896, when there were three cases of yaws in her line. On
August 2, 1896, she was admitted to hospital by my locum tenens with an initial yaw
on the site of the gumma. She remained under my treatment till December, 1897.

Case LI.—Her father, blind from iritis with occlusion of pupils since about 1882,
had been under my care for nodes and gummata. In December, 1898, he had a
vesiculo-pustular eruption on both feet, doubtless due to ankylostome larva?. In
January 1899, he had a primary yaw below the left inner malleolus, followed by a
general eruption. He died of ankylostomiasis in December, 1899.

Section of Tropical Diseases and Parasitology 41

Case LIII had a gumma on the right leg which broke down leaving an ulcer
Some months after a primary yaw appeared on the ulcer. In spite of vigorous
cauterizing with nitric acid a general eruption followed. Some of the scarring is due
to the nitric acid.

Castellani describes a cracked and pitted form of plantar hyperkeratosis as
a sequel of yaws. This form of hyperkeratosis is very common in Assam,
where the coolies call it “ pachwari.” It is not rare elsewhere in India.

I show you a photograph of a case in Bombay, where yaws does not exist.
I cannot in any way regard this condition as due to yaws. I have seen it in
hundreds of Indians who never had yaws, and I have seen four of these
patients develop a primary yaw on a fissure or pit on the sole and some others
become infected with yaws elsewhere. Another photograph shows a similar
condition of the palms which had existed for years. A sparse eruption of
yaws has just broken out on the trunk.

Gangosa.

In Assam and in Bombay I hfive diagnosed several cases as tertiary
syphilitic destruction of the face, which were regarded and even published by
my colleagues as “ Gangosa.” None of them ever had yaws. All were in
races among whom yaws had never been seen. I show a photograph of a
Mussulman Bengali who had had syphilis seven years previously. He was
treated with iodides and calomel fumigation; the necrosing bones were
removed, and the result is seen in the photograph. The first Bengali to have
yaws was the doctor at Nuncherra, who in 1899 contracted the initial yaw on
a “ hang-nail ” on the right ring finger. His two children and a Bengali
servant were infected later.

Heredity.

I have never seen any case of hereditary transmission. With the exception
of Case XXV, the youngest I have seen was seven months old, and, as well as
I can recollect, in all children below the age of eighteen months the primary
lesion and the breach of skin on which it was inoculated were identified. I
have seen seventeen healthy babies bom of parents who had yaws during
pregnancy. They remained healthy, except for malaria, or dysentery in two
cases. With the exception of scabies there was no rash in any case. I show
four photographs of children from 8 to 16 months old, all of whose parents
had yaws when the children were born. They all look “ bonny,” and might
serve on a patent food advertisement.

Goodman [10] and Schiiffner [42], by means of the X-rays, have seen
bone or periosteal changes at the onset of the general eruption. If this be so,
it would not be surprising to find bone lesions later on. The absence of tertiary
changes in my cases may be exceptional, yet much of the literature describing
tertiary yaws is very unconvincing and much of its logic deplorable.

With many it is an axiom that there is no syphilis in Fiji, therefore all
nodes, gummata and destructive lesions of bone wmst be due to yaws. Thirty
years ago I had a patient who assured me he had contracted syphilis from a
Fijian woman. A quarter of a century ago there were in Fiji about ten
thousand Indian coolies of the same class and from the same districts as those
of Assam. I cannot believe they were all free from syphilis. Thirty years
ago missionaries were deploring the spread of syphilis in Fiji. Its prevalence
was one of Mr. Ghandi’s arguments for the abolition of the Indenture Acts.
Nearly a quarter of the population twenty years ago was made up of Indians,

Powell: Framboesia

Europeans, Chinese, Polynesians and half-castes, these last a proof of the
frequence of inter-racial intercourse. Finucane says syphilis is extremely
common among the coolies of Fiji, that the Fijians are very immoral and have
ample opportunities of contracting syphilis. “ Typical cases of hereditary
syphilis are seen,” also “ eruptions in Fijians which, if seen in a European, he
would have pronounced syphilis.” But obsessed by the “axiom” he calls
them yaws ! Most of the photographs of “ Tertiary Yaws Lesions in Fiji ” I
have seen are those of Indian coolies.

Harper [15] agrees with Daniels that syphilis is absent, and therefore the
few cases of tabes he has seen must be due to yaws ! Maxwell says the tertiary
signs of yaws he saw were “ in those suffering from leprosy or the malus
corporis habitus,” which seems to me to be a polite term for syphilis.

Rat [37] describes as tertiary yaws “ severe forms of ulceration resembling
excedent lupus” which, “as they generally occur in the scrofulous, usually pre¬
sent the appearances common to that disease.” Why, then, not call them
lupus or scrofula rather than tertiary yaws ?

REFERENCES.

[1] Baermann and Wetter, Muivch. med. Wochenschr ., 1910, lvii. [2] Bestion, Annales de
Med. Navale, 1881. [3] Brocq, “ Cours de Dermatologie Exotique.” [4J Byam and Archibald,

“ Medicine in the Tropics,” ii. [5] Castellani and Chalmers, “Manual of Tropical Medicine,"
3rd ed. [6] Charlouis, Vierteljahrs. f. Derm, und Syph., 1881, viii. [7] Connor, Powell,
Ind. Med. Gaz., 1906. [8J Daniels, C. W., Brit. Journ. Derm.,, 1896, viii: Arch, of Surg.

[9] Finucane, Journ. Trop. Med., 1901. [10j Goodman. Arch, of Derm, and Syph., July, 1920.

[11] GOUZIEN, Annales a*Hygiene et Med. Coloniale , No. 3, 1904. [12] Haffkine, W. M.,

Personal Communication. [13J Halberstaedter, Arbeiten a. d. Kaiserhch. Gesundheitsamte,
1907, xxvi. [14 1 Hare, E. Christian, Personal Communication, f 15 J Harper, Lancet, 1916,
ii, p. 678. [16] Henogeler, Monats. f. Brae. Derm., 1904, xl. [17] Hirsch, “Handbuch der

historisch-geographischen Pathologie," 1881. [18] HuiLLET, “Hygiene des Blancs, Arc., de

Pondichery," 1861. [19] Hutchinson, Sir J. (a) Arch, of Surg., 1896; (6) New Sydenham

Society, Fasciculus 13; (c) Polyclinic. [20] JEANSELME (a) La Prat. Derm., iii; (6) Gaz. Hebd. deMed.,
1901; (c) Brouardel and Gilbert’s “Nouveau Traite de M6d.,” vi. [21] Koch, R., Arch. f. Derm, und
Syph., 1902, lix, Heft 1. [22 J M’Carthy, Ind. Med. Gaz., 1906, p. 53. [23] Maitland, Ind. Med.

Gaz., October, 1894. (24] Manson-Bahr, “Tropical Diseases.” [25] Maxwell, “Observations

on Yaws," Edin., 1839. [26] Milroy, Report on Yaws and Leprosy in West Indies, 1873. [27]

Nattan-Larrier and Levaditi, Comptes rend. Soc. Biol., 1908, lxiv. [28] Netsser, Baermann
and HalbersTadter, Munch, med. Wochenschr., 1906, liii. [29] Neisser (a) Arb. a. d. Kaiserl.
Gemnd., 1911, xxxvii; (b) Arch. f. Schiffs- und Trop.-Hygiene, 1908. [30] Nicholls, Report on

Yaws in Tobago, Arc., 1894. [31] Nolan, Trans. Ind. Med. Congress, 1894. [32] Paulet,

Archives generates de Med., 1848, ii and iii. [33] PILGRIM, Ind. Med. Gaz., 1906, xxxi, p. 279.
[34] Plehn, Meuse’s “ Handbuch der Tropenkrankheiten,” i. [35] Powell («) Ind. Med. Gaz.,
1894, 1897, and 1898; (b) Trans. Ind. Med. Congress, 1894; (c) Brit. Journ. Derm., 1896. [361

RANKIN, Brit. Med. Journ., 1912, i. [37] Rat, J. Numa (a) "Yaws: Its Nature and Treatment.”
1891; (b) Journ. Trop. Med., 1904. [38] Rochas, “Topographic Hygienique et Med. de la Nouv.

Caledonie,” 1860 ; “ Dictionnaire Encyclopedique des Sciences Med.,” 1879. [39] Salanoue-Ipix.

Grail and Clarac’s “ Pathologie Exotique," 1919, viii. [40] Scherschmidt, Arch. f. Schiffs- und
Tropen-Hyg., 1913, xvii. [41] Scheube, “Krankheiten der warmen Lander,” 1910. [42]

Schuffner, Munch, med. Wochenschr., 1907, xxii.

Section of (Tropical Dioeaseo ant) parasitoloas

President—Sir Leonard Rogers, C.I.E., M.D., F.R.S.

The Lung Flukes of the Genus Paragonimus :

A Demonstration.

By G. M. Vevers, L.R.C.P.Lond., M.R.C.S.Eng.

(Beit Research Fellow.)

The genus Paragonimus contains all the mammalian lung flukes of America
and the Far East. At present there are five known species: —

Host

(1) Paragonimus rudis Diesing 1850. Brazilian otter ...

(2) ,, compactus Cobbold 1859 ... Indian mongoose

(3) ,, westermanii Herbert 1878 Tiger, leopard, man .

(4) ,, ringeri Cobbold 1880 ... Man, dog, pig, cat

(5) ,, keliicotti Ward 1908 ... Dog, cat, pig

Paragonimus rudis was found in a Brazilian otter. We know very little
about it as the description by Diesing is short and it has never been found
since 1850. Its occurrence in the New World however is suggestive that
it is identical with Paragonimus keliicotti .

Paragonimus compactus , although described so long ago as 1859, was not
found again until two years ago when I collected it from the lungs of the
Indian mongoose, the type host, at a post-mortem at the Zoological Gardens ;
since then it has been found in the same host on two other occasions, also at
the Zoological Gardens.

Paragonimus westermanii .—The type of the genus was first described in
a paper by Herbert in 1878.

Paragonimus ringeri was described by Cobbold in 1880 from a specimen
coughed up by a Portuguese in China and sent to him for diagnosis by the
late Sir Patrick Manson. This was the first record of a lung fluke occurring
in man.

Leuckart and others considered that the two last flukes were identical and
therefore the name Paragonimus ringeri was dropped for a time in favour
of Paragonimus westermanii .

In 1894 a lung fluke was found in North America. At first it was
thought to be imported from Asia, but the subsequent discovery of the fluke in
the dog and pig in various parts of the States proved that a lung fluke was
endemic in the New World. This fluke for some time was considered by
Ward and others to be a variety of Paragonimus westermanii . However

Au—T b 1 [March 5, 1923.

Geographical

distribution.

Brazil

India

India and Malay
Japan

America and Malay

44 Yevers: Lung Flukes; Ortlepp: Life-history of Gape-worm

in 1908 Ward described it as new and named it Paragonimus kellicotti , after
Kellicott, who first discovered it in the United States.

Up till 1915 all the workers on the genus had relied on the shape, size
and position of the internal organs as specific characters. Although these
characters may be of great use in dividing up other Trematode genera into
species such as the genera Opisthorchis, Heterophyes and others, there is so
much variability in the internal organs of individuals of any one species
of Paragonimus that one cannot rely on these points to any great extent.

In 1915 Ward and Hirsch in the U.S.A. discovered an easier way of
differentiating between the species. They found out that the cuticular spines
which are present in all these species differ in shape, size and arrangement in
a constant manner.

From the material I obtained at the Zoological Gardens I have been able
to show that the cuticular spines of Paragonimus compactus differ from the
spines of the other members of the genus and also that the arrangement and
shape of the spines in this species are constant in a large number of individuals,
thus confirming Ward and Hirsch's view that the shape and arrangement of
the cuticular spines are the only reliable characters upon which one can split
up this difficult genus.

If one takes the sizes of the eggs of various human cases of paragonimiasis
given by different authors one finds that they vary in size from 70 by 45 /i-
to 100 ft by 60 ft. This range of size is far beyond that of the variations in
the eggs of any one particular species.

Hitherto it has been supposed that man in the East is parasitized by only
one species of lung fluke—this has been called Paragonimus ringeri by some
and Paragonimus westermanii by others. A comparison of the eggs of the four
best known species brings to light several obvious differences in contour,
thickness of shell and size. It is therefore certain that more than one species
of Paragonimus occurs in man— probably three : Paragonimus ringeri , Para¬
gonimus westermanii , and Paragonimus compactus . In connexion with this it
is interesting to note the geographical distribution of the different species.

The object of this demonstration is : (l) To show the value of the cuticular
spines in the diagnosis of the different species. (2) To make a comparison of
the eggs of the four species showing the chief points of difference. (3) To
demonstrate adult flukes of the species Paragonimus westermanii , Paragonimus
kellicotti , Paragonimus compactus taken from their various hosts in the
Zoological Gardens of London.

Life-history of the Gape-worm.

By R. J. Ortlepp.

(ABSTRACT.)

The exhibitor showed a series of preparations illustrating some hitherto
undescribed stages in the life-history of Syngamus trachealis % the common
gape-worm of chickens; these preparations included some sections of the
lungs of chickens showing the parasite in development, on successive days
after infection, until their appearance in their final habitat, the trachea.

The demonstration was preceded by a short account of the work previously
done on this parasite.

Section of Tropical Diseases and Parasitology

Life-History of the Sandfly, Phlebolomus papatasii.

By Wing-Commander H. E. Whittingham, R.A.F.M.S.

(ABSTRACT.)

The author detailed the life-history of the sandfly, Phlebotomies papatasii ,
and illustrated his remarks by a large number of specimens and drawings.
He stated that the Royal Air Force Sandfly Fever Commission has shown that
the virus of phlebotomus fever was transmitted from generation to generation
of Phlebotomus papatasii . This may be effected in two ways, either it is
transmitted by heredity or the larvae infect themselves in the breeding grounds
by eating the excreta or the dead bodies of the parent flies. It follows that
prophylactic measures against the fever must be directed upon the fly, the
habits and habitats of which must be understood.

The life-history of Phlebotomus papatasii covers a period of about six weeks,
the exact time depending on conditions of temperature and humidity. The
ovum, which measures 0*385 mm. in length by 0*12 mm. in breadth, in its
development shows certain changes in its surface markings and on the ninth
day caudal bristles appear. A few hours later the shell breaks on the dorsum
by the action of the egg-tooth. The larva emerges and enters on its first
instar, lasting six days and ending with the first moult. In all, the larva
passes through four instars of about six days each; and four moults, during
which there occur not only increase in size but developmental changes
characterizing each period, such as the disappearance of the egg-tooth, the
appearance of two and then four caudal bristles, and of one and then two dark
pigment bands on the dorsum of the terminal segments of the body. With the
conclusion of the fourth instar the larva enters on the pupal stage, lasting
about nine days, before the emergence of the imago. The wings of the newly
hatched fly are crumpled and moist. Until these dry the young fly can only
crawl. The recognition of this stage is most helpful in detecting the breeding
spots of the insect. During the night, when the atmospheric humidity is
usually great, the wings cannot dry. The process of drying is generally
completed within three hours after dawn, and the mouth parts harden to allow
of the sucking of blood during the first twenty-four hours of adult life.
Copulation can take place within the next twenty-four hours, and eggs to the
number of forty are laid six to ten days later. The length of life of the adult
female fly in nature is about two weeks, though in the laboratory life may be
prolonged for thirty days or more. It should be noted that, in the summer,
only a third of the life of the insect is spent in the imago stage.

It has been found possible, as in the specimens shown of the living larvae
and adult flies, to prolong the larval stage considerably by the retarding effect
of increased moisture or lowered atmospheric temperature. Hibernation of the
insect occurs in the fourth larval stage. Several larvaB have been kept in this
stage for six months, and then, by reducing the amount of moisture and
incubating at 80° F., pupation has occurred. Fully-formed imagines eventually
hatched out of the pupae.

Broughton-Alcock: Spirochsetal Dysentery

Case of Spirochsetal Dysentery.

By W. Broughton-Alcock, M.B.

(ABSTRACT.)

The author demonstrated a series of slides showing intestinal mucus
crowded with Spirochaeta eurygyrata , faecal matter from another case showing
Spirochaeta stenogyrata and a third specimen showing Spirochaeta eurygyrata
in the mucous portion and Spirochaeta stenogyrata in the faecal portion of the
same stool. He discussed the question as to whether these are two forms of
one and the same organism or two separate species of Spirochaeta , saying that
authors appear divided upon this question. He then continued as follows :—

Miss Hogue, in America, has recently published a very interesting article in
the Journal of Experimental Medicine, December 1, 1922, describing cultures of
Spirochaeta eurygyrata but the illustrations drawn are, unfortunately, few, and
are unlike the Spirochaeta eurygyrata as I have always seen this organism, and
as illustrated by Le Dantec 1903, Fantham and others. Unfortunately, also,
there is only complimentary reference to the narrow coil type of Werner seen
in the faecal portion of many normal stools and obviously non-pathogenic, since
it is never found in the mucous portion nor characterized by association with
a dysenteric, diarrhoeic or catarrhal colitis condition. As to the pathogenicity
of Spirochaeta eurygyrata , my experience leads me to believe that it can produce
a catarrhal condition with the passage of mucus containing shed degenerated
epithelial lining cells, occasionally red blood cells, and, what is extremely rare
such a case as was seen in a first attack with typical dysenteric symptoms
and passage for three weeks of much blood with non-purulent mucus. The
mucus was teeming with Spirochaeta eurygyrata and no other cetiological cause
could be found on repeated microscopical and cultural examinations. There is
always the argument that a primary agent has produced a vulnerable surface
over the organism and acts symbiotically. This remains unanswered. Observa¬
tions have been made on more than 20,000 stool examinations and neither my
assistants nor myself have found the Spirochaeta eurygyrata unassociated with
mucus in which it is contained. The condition as seen in Britain is a chronic
one with a mild degree of general symptoms. The main disability is the
persistent or intermittent slight looseness and increased number of mucus-
containing stools and the occasionally noted onset of acute symptoms with
mild intestinal pain following dietary indiscretion or a so far undetermined
cause. The infection is not common nor has an epidemic character been
observed. I have observed only one case in England ; the endemic areas
appear to be in tropical and subtropical countries.

A patient, a case of such infection, has kindly presented himself this
evening. He, a Fellow of this Society, is a healthy and robust medical
practitioner. He stated that in 1917 he had, when in the Balkans, a moderately
severe diarrhoeic attack with passage of mucus and accompanying feeling of
malaise. No amoeba and no bacillus of the enterica or dysenterica groups was
found. Occasionally, after dietary imprudence, such as too heavy a dinner, a
recurrence of the symptoms lasting three to five days follows. Much mucus
is then passed and this I have found packed with the large-coil Spirochaeta
eurygyrata . No other organism to which pathogenicity could be attached was
found. He has cleared up the acute attack by taking a small dose of calomel
nightly for three or four nights, followed by saline in the morning.

I think there is insufficient evidence in the publication to accept Dr.
Fantham’s interpretation from his observations cited in the British Medical

Section of Tropical Diseases and Parasitology 47

Journal , June 10, 1916, to which members are referred for an excellent
revision of the question and references. It was unfortunate that Dr. and
Mrs. Fantham were not in England to record their observations in South
Africa. I have not been able to follow any transformation of form, and to my
observation the narrow coiled Spirochaeta stenogyrata possesses much less
motility, less defined border, is narrower, more frequently bowed and bended
than the more sturdy active Spirochaeta mrygyrata , is found only in the faecal
portion of the stool, and is not infrequently seen in a normal stool. While the
possibility of morphological variation according to activity or environment is
not denied, evidence of such appears to me as yet insufficient for the Spiro -
chaetae to be classified as of one species, as against the original classification of
Werner. 1

Attempts to infect mice with the Spirochaeta eurygyrata have been un¬
successful. A slide showing Spirochaeta bronchialis is also exhibited so that
the Spirochaetae may be compared.

Remarks upon a Photograph of an Endemic Focus of Bilharzia
Disease in Portugal; Specimens of the Intermediary Host,
Planorbis dufourii (Graells).

By J. B. Christopherson, C.B.E., M.D.

In December, 1921, Dr. Carlos Francja, of Collares, Lisbon, reported cases
of bilharzia disease occurring in the south of Portugal; he found an endemic
focus in the Atalaia (St. Luzia) quarter of Tavira—in the province of Algarve.
He sent me a photograph of the infected spot and specimens of the inter¬
mediate host, both of which I am showing to-night.

It was discovered that at Tavira only washerwomen ^witn the exception of
a boy, aged 13) were infected, and only those washerwomen who washed
clothes in a certain tank, formed by water retained in a natural excavation in
the limestone (6*3 metres by 7*3 metres) ; the water being constantly renewed
by a thermal spring is always at a temperature of 25° C. At least sixteen out
of the sixty-four washerwomen who used this tank were infected with vesical
bilharzia.

The thermal tank is inhabited by a snail of the species Planorbis dtifourii
and the snails were found by Dr. Fran§a to be infected with the cercaria of
bilharzia disease. The women who remain standing washing clothes in the
water for many hours a day are infected in the usual way, that is, through
the skin. They in turn help to complete the necessary biological cycle
by micturating into the water whilst at work and in this way reinfect the
snails.

The tank possibly received its original infection either from a washer¬
woman returned from the North of Africa (Morocco) or from a soldier in the
adjacent hospital returned from Portuguese West Africa (Angola) or Portuguese
East Africa (Mozambique), in all of which places Schistosoma haematobium is
present.

It might be thought that the infection of the tank occurred in con¬
sequence of the temperature of the water (25° C.). This is not so, for in
December, 1922, Dr. Carlos Fra^a recorded another focus of infection in
Portugal, at Alportal, a short distance from Tavira. Here the river was
infected, and the temperature of the water when taken was 13° C. Both men
and women were infected at Alportal.

x Centralbl. f. Bakt., 1909, orig., 1 Abt., lii, pp. 241-243.

48 Christopherson: BilharziaDisease; Robertson: Dientamoeba

With regard to the intermediary host the parasite of Portuguese bilharzia
disease is Schistosoma haematobium and the intermediary host Planorbis dufourii
(Graells). In Portugal no species of the Bullinus genus of molluscs is to be
found, and it would appear that Schistosoma haematobium has adapted itself to
a snail belonging to the genus Planorbis which it has selected in the absence
of Bullinus .

Portugal is the only country in Europe definitely known at the present to
be endemically infected with bilharzia disease; other foci of infection in Europe
will doubtless be found, especially in countries bordering on the Mediterranean. 1
It would appear that possible intermediary hosts for Schistosoma haematobium
are widespread in Europe.

Specimens from a Human Case of Infection with Dientamoeba
fragilis, Jepps and Dobell, 1917.

By Andrew Robertson, M.B.

(Assistant in Protozoology , London School of Tropical Medicine ; Grocers' Bescareli Scholar.)

The patient, from whom the material was derived, had been resident in
London since 1919, but had lived abroad for some years before that date. The
only history of previous intestinal disorder was in 1919, just before he returned
to this country, when he had a diarrhoeic attack, which cleared up with the
evacuation of an Ascaris lumbricoides. In spite of the fact that the patient’s
faeces had been examined repeatedly at irregular intervals no protozoa were
noted until the present occasion. Towards the end of January of this year he
had an attack of diarrhoea associated with some form of food poisoning or
dietetic indiscretion, and in the semifluid stool numerous free Entamoeba coli
were found. This stool was submitted for further study within about ten
minutes of being passed, and, in addition to the free Entamoeba coli already
mentioned, there proved to be present a fairly heavy infection of Dientamoeba
fragilis , numerous Blastocystis hominis and a very few ova of Trichuris trichiura .
In two subsequent stools, one of which was almost constipated in character,
the Blastocystis and Dientamcebae were still present.

In all six specimens are shown. Nos. 1 to 4 are binucleate individuals and
show the marked differentiation between the clear, hyaline ectoplasm and the
more granular, vacuolated endoplasm in which various bacterial inclusions can
be made out. The nuclei are of the characteristic type, being spherical in
shape, vesicular and having very thin nuclear membranes. The nuclear
chromatin appeared to be arranged in the form of a ring of granules, most
frequently five in number, towards the centre of the nucleus.

No. 5 is a binucleate Dientamoeba at an early stage in the process of
degeneration. There is a ring of cytoplasm, thicker towards one pole, and
including the two nuclei, surrounding a large vacuole filled with homogeneous
material.

No. 6 : This specimen is a uninucleate individual, and its characters, except
for the fact that it has only one nucleus, are similar to the binucleate forms
above described. The proportion of uninucleate to binucleate individuals in
this case was about one to four.

No cystic stage of this parasite has been made out.

i It is doubtful whether Greece is endemically infected. Cyprus is infected, but it is not in
Europe proper.

Section of {Tropical Dioeaoes anO parasitology

President—Sir Leonard Rogers, C.I.E., M.D., F.R.S.

The Establishment of an Antirabic Institute in the Tropics

By A. E. Hamerton, C.M.G., D.S.O., Lieutenant-Colonel

R.A.M.C.

The fact that Pasteur Institutes are now features of preventive medicine
wherever the dread disease of rabies prevails is, perhaps, one of the most noble
tributes to the genius of Pasteur.

In the tropics, hitherto it has been customary to establish antirabic insti¬
tutes in the temperate climate of hill stations often far removed from centres of
population in the endemic areas of the disease.

During the expansion of our civilization in the East and in Africa, and
under the conditions of military service, it is not unlikely that the treatment
of rabies will sometimes have to be undertaken on the plains, where most
torrid conditions of climate are present. Such was the case in Mesopotamia.

During the Great War and the subsequent rebellion in Irak considerable
loss of service and expense to Government were caused by the lack of local
facilities for the treatment of rabies. Between 200 and 300 men had to be
sent every year to the Pasteur Institute at Kasauli for antirabic vaccination.
In addition, the unavoidable delays in the long journey from up-country
stations in Irak resulted in the death from hydrophobia of a number of
soldiers who—arriving in India too late for effective treatment—succumbed to
this disease en route to Kasauli, or soon after arrival there. As long ago as
1910, Colonel Sir David Semple, R.A.M.C. [l], following the lead of Fermi and
anticipating the needs of a large field force operating in the East, perfected a
simple method of preparing a safe and efficient antirabic vaccine that any
competent bacteriologist could carry out for the treatment of rabies locally, at
a base or central laboratory.

The vaccine is prepared by emulsifying the brains of rabbits that have
died from inoculation with “fixed” rabies virus, in a dilution of carbolic acid
of sufficient strength to kill the virus, but insufficient to destroy the anti¬
bodies present in the affected nerve tissue or to destroy its immunizing
properties. This carbolized vaccine has stood the test of statistical examina¬
tion and animal experiment by many investigators working independently,
and has been used for many years as the standard antirabic treatment in
all Pasteur Institutes throughout the Empire [2]. It is proposed to record
here a few general remarks on the incidence of rabies in Irak, and to outline
the method adopted in working a Pasteur Institute in Bagdad, for the informa¬
tion of those who in future may find the necessity of establishing a similar
institute under like conditions of tropical climate.

[May 7, 1923.

60 Hamerton: An Antirabic Institute in the Tropics

The Occurrence of Babies in Irak.

Rabies in dogs and hydrophobia in man were recognized by medical prac¬
titioners in Bagdad long before the British occupation. For many years Arab
“Hakims” in country districts have been acquainted with “madness” in
dogs, and have regarded their bites, when mad, as fatal to mankind. In like
manner, they deem a bite from a wolf or jackal to be especially dangerous.
Their knowledge of the pathology of rabies is, however, chimerical.

Early in the late war canine rabies was detected by the Military Medical
and Veterinary Services in Irak. As the Army, with its following of pet dogs,
accumulated, and it became known throughout the Force that a dog-bite,
real or spurious, would elicit a passport from the infernal regions of Irak to the
delectable mountains of India, so the military establishment became depleted by
an increasing stream of personnel passed over to Kasauli for antirabic treatment.
There was undoubtedly a good deal of malingering, but since deaths from
hydrophobia had actually occurred in the country, no medical officer could
undertake the responsibility of denying antirabic treatment to any patient
who presented a wound alleged to have been caused by a bite of dog or jackal
that might have been rabid.

During 1919 a remarkable series of cases of hydrophobia occurred in a
refugee camp at Bacuba, in which forty-six persons were bitten by a rabid
jackal which ran amok in the camp. Twenty-eight of the men bitten were
sent to Kasauli for antirabic treatment. They arrived fifteen days too
late, and five of them died of hydrophobia during, or shortly after,
treatment.

Of the eighteen people—some of whom were women and children—who
were not sent to Kasauli, eleven of them died of hydrophobia in the Military
Hospital at Bacuba. The death-rate amongst the treated cases was 17*9 per
cent. The death-rate amongst the untreated was 61*1 per cent. The figures
are taken from official records, and I have verified them from correspondence
in the Central Laboratory, Bagdad, where the diagnosis of four of the fatal
cases at Bacuba was confirmed by histological investigation.

In the year 1920, 50 Europeans and 212 Indians were dispatched to Kasauli
for antirabic treatment, and in the first six months of 1921, 58 Europeans
and 167 Indians were sent to Kasauli. Of these 487 patients, three British
soldiers and three Indians arrived too late for effective treatment and died of
hydrophobia.

It is difficult to obtain trustworthy evidence regarding the prevalence of
hydrophobia amongst the civil population. The Director of the Civil Hospital,
Bagdad, informed me that he had seen four cases in that city during the last
three years.

The disastrous effects of a rabid animal running amok in a native
village, and the beneficial effects of early vaccine treatment are exemplified
by the following well-authenticated case, details of which were kindly given
to me by the Director of Health Services, Irak, and by Dr. Corner, the
civil surgeon at Kirkuk, who personally investigated the cause of death of
the victims.

In November, 1921, an important Sheik and his daughter attended the Central
Laboratory, Bagdad, for antirabic treatment. The man was severely bitten on the
hand by a wolf, the girl was also dangerously bitten on the face. The civil
surgeon at Kirkuk, who sent the patients for treatment, reported that eight other
persons in the village had been bitten by the same wolf, but refused to attend for

Section of Tropical Diseases and Parasitology

treatment. I communicated with Dr. Comer, requesting him to keep an eye on
all the people who were bitten. Four months afterwards he reported as follows:—
“ The Sheik of Kifri and his daughter are alive and well. Of the other eight
persons bitten, two women and six men developed hydrophobia and died ; also
three donkeys bitten by the same wolf have died. A cow that was bitten likewise
sickened of the disease, but was slaughtered and eaten by the natives.”

It is impossible to stamp out rabies in tropical countries, because jackals,
wolves, and, in East Africa, hyaenas provide a natural reservoir for the virus,
and these animals, when rabid, will raid the villages and infect the dogs of the
inhabitants and sometimes the people.

In tropical countries the diagnosis of rabies in dogs and animals
devolves almost entirely on the laboratory, to which dogs* heads in all
stages of decomposition are brought in large numbers whenever rabies is
notified.

Negri bodies are found in the brain of 97 per cent, of rabid animals, and
their presence in the pyramidal cells or the cells of Purkinje is generally
accepted as conclusive proof of rabies; but, unfortunately, one cannot infer the
contrary if they are not found.

In making preparations for diagnosis by the microscope I have found that
in the tropics the following method of staining gives the best results [3] :—

Tissue for section may be fixed in the usual way. Smears of the hippo¬
campus major should be fixed wet in methyl alcohol. To make up the
stain, put 50 c.c. of distilled water in a measure glass—add three drops of
saturated aqueous solution of methylene blue, shake up and then add four
drops of saturated alcoholic solution of basic fuchsin (if permanent section
preparations are required make the stain up in 50 c.c. of a 5 per cent, solution
of carbolic acid instead of water) ; then flood the smear with the stain
for five minutes, heating gently until steam arises. Examine under a low
power objective and look for pyramidal cells, which will often be found clumped
together in one part of the film. They should be stained light blue: if densely
stained soak the slide in water and control the decolorizing under £ in.
objective.

Preparations thus obtained have the advantage of presenting various depths
of staining, some parts being too heavily staine d, other too lightly, whilst in
the intervening parts Negri bodies appear under the ^ in. objective as brilliant
pink dots, globules or oval bodies, in a light blue mounting formed by the
pyramidal cells. Careful focusing will reveal in the depths of the Negri
body a few dull bluish points or granules. If the stain is made up with
5 per cent, carbolic solution instead of water, the Negri bodies take a bright
ruby red colour in contrast to the cell nuclei which stain deep purple or
chestnut.

Negri bodies may be so numerous as to be present in nearly every
pyramidal cell, or they may be so scarce as to require prolonged search through
many slides before a typical and indisputable specimen can be found. In
canine and jackal rabies, however, they are generally found at once in smear
preparations, and an immediate diagnosis can be made without the necessity of
cutting sections. If the finding in smears is difficult or uncertain, stained
sections should always be examined before an opinion is pronounced.

In cases in which the finding of Negri bodies was controlled by biological
test, the rabbits died of rabies between the sixteenth and nineteenth day
after subdural inoculation with 0*2 c.c. emulsion of the cerebellum of the sus¬
pected animal. In one case in which prolonged search failed to reveal Negr

52 Hamerton: An Antirabic Institute in the Tropics

bodies, but in which the clinical evidence was convincing, the biological test
proved positive.

I consider it important that in the first case or two that occur in a district
the presence of rabies should be biologically proved; for if the diagnosis is
unquestionably rabies, then more cases may be expected, and due precautions
should be enforced without delay. In cases in which there is a clinical sus¬
picion of rabies, but which prove negative on investigation for Negri bodies,
the biological test should be made.

The necessary subdural inoculation of a couple of rabbits or guinea-pigs
can easily be done without any special instruments. A cork-borer of about
§ in. calibre does very well instead of a trephine; forceps, a scalpel and a little
surgical handicraft are presumably always available.

The Manufacture of Antirabic Vaccine.

The vaccine is made, as will be described presently, from the fresh brains
of rabbits that have died as a result of subdural inoculation with “ fixed
rabies ” virus. A local strain of fixed virus may be acquired from the original
‘‘ wild ” virus as found in the fresh brain of a naturally infected rabid dog, wolf
or jackal, and commonly termed “street ” virus. This “street ” virus, when
inoculated subdurally upon a rabbit’s brain, has a variable incubation period
of from fourteen to thirty days preceding the onset of symptoms.

If a strain of this virus is carried on from rabbit to rabbit by subdural
inoculations of brain substance, the virulence of the poison becomes curiously
altered in that the incubation period diminishes—possibly because of more
rapid proliferation of the virus by successive “ passages ” through rabbits—
until after some thirty or more of such inoculations we find the period of
incubation of the disease has become reduced to a fixed limit of about seven
days, followed by death not later than the tenth day. In contrast to the
original “ street ” virus, however, the fixed virus—when injected subcutaneously
—appears to be incapable of penetrating to the higher nerve centres and
causing symptoms. It would be interesting, however, to have more
experimental data on this matter, the explanation of which seems obscure.

Since the preparation of fixed virus is tedious and expensive in animals, it
is convenient to obtain the strain of fixed virus from one of the Pasteur
Institutes already established. It must be remembered that the virus is
extremely delicate, and in hot weather would probably be killed during trans¬
mission through the post. Aeroplane transport would solve this difficulty,
but in Bagdad it was necessary to get the virus sent over from Kasauli
in live rabbits, relays of which were subinoculated as required during the
journey.

A virus, killing on the tenth day, is inoculated into a rabbit in the
usual way. On the sixth or seventh day after the operation it will be
observed, on disturbing the rabbit, that it has lost the power of judging
the distance and the muscular effort required in jumping from one side to
the other of its cage. The animal takes too forcible a spring and strikes
its nose against the wall towards which it jumps. This very early and,
I believe, characteristic symptom of fixed virus infection should be noted.
Within twenty-four hours of this first symptom appearing, a very fine tremor
of the ears and head will be observed, and the next day, if taken out of its
cage and allowed to run about, the creature will be seen to have a reeling gait,
as though intoxicated. On the ninth or tenth day it will be dead or dying.
If it dies on the ninth day, its brain can be used for the preparation of vaccine

Section of Tropical Diseases and Parasitology 53

only. If it survives until the tenth day, and is then obviously moribund,
it can be used for subinoculation or “passage/* and for the preparation of
vaccine also. If, however, the rabbit has died before the ninth day, its death
has been caused by some intercurrent malady, and the animal should be
discarded. During a period of intense heat in Bagdad, the virus seemed
to lose its strength and did not kill until the twelfth or thirteenth day after
inoculation. One passage of the virus through a guinea-pig, however, was
followed by the restoration of its original lethal effect on rabbits, in which
it remained stable, killing on the tenth day until last summer, when, I am
informed, it had to be ‘ restored *’ again, this time by passage through a
monkey. The stock virus should be maintained by passage from rabbits
dying only on the tenth day. Occasionally a rabbit escapes and does not die.
Such an event is probably due to a defect in technique, and will be of very rare
occurrence after a little practice and careful attention to detail, which I have
described in the Journal of the Royal Army Medical Corps for December, 1922.
Assuming that the inoculated rabbit is dead or dying on the tenth day, it
should be disinfected by immersion in a pail of cresol for a couple of minutes.
The floor of the room and the operating table should be swabbed with cresol;
the dead rabbit laid out with its head resting on the edge of the table and its
legs tied out behind. The top of the rabbit’s skull is then exposed by
reflecting the skin from each side of a median incision extending from the nape
of the neck to the muzzle, care being taken not to open the orbital or aural
cavities. The skull is then swabbed with 1 in 20 carbolic and the site of the
trephine hole seared with a hot iron. A culture is taken from the brain
by passing a platinum needle through the trephine hole and inoculating tubes
of broth and agar. The skull is then chipped away and the brain exposed.
It should be normal in appearance and the surrounding tissue should be free
from any inflammatory reaction. A portion of the cerebellum is snipped off
and preserved in equal parts of glycerine and distilled water, not saline
solution, which would weaken the virus. This is the reserve supply of the
virus, which should be sealed up in the tube and kept in ice to be used in
the event of any mishap to the rabbit to be inoculated with another small
piece of the fresh cerebellum emulsified in sterile distilled water.

Having thus provided for continuation of the strain of fixed virus, the whole
brain is then removed under strict aseptic conditions, weighed and thoroughly
triturated in a mortar. A solution containing 1 per cent, of phenol in 0*8 per
cent, salt solution is slowly mixed with it until a suspension of 1 in 50 of brain
substance has been obtained. This is placed in an incubator at 37° C. for
twenty-four hours, a treatment which is sufficient to kill the virus. The
suspension is then diluted with an equal part of 0'85 per cent, salt solution and
samples are taken which are tested for sterility, aerobically and anaerobically
in broth and agar. The suspension of the virus is stored at 0° C. between
blocks of ice in an ice-chest until the sterility tests have been completed, and
subsequently until required for use. Under these conditions the carbolized
vaccine retains its full potency for at least three months. It should not be
used beyond three months from date of manufacture.

Before inoculation the suspension—which should be stored in hermetically-
sealed rubber-capped bottles holding 25 c.c. — is withdrawn by means of a
syringe sterilized in hot oil (140° C.) and again diluted with an equal part of
0‘85 per cent, salt solution ; so that the vaccine finally contains 0'5 per cent,
of brain substance, 0’25 per cent, of phenol, and 0’85 per cent, of salt.

Each patient, however severely bitten, received daily doses of 5 c.c. of this

54 Hamerton: An Antirabic Institute in the Tropics

suspension for a period of fourteen days : 2£ c.c. are inoculated on either side
of the middle line of the abdomen by inserting the point of the needle at an
acute angle between the superficial and deep layers of the skin and pressing
out the vaccine between the epidermis and dermis, i.e. f intracutaneously rather
than subcutaneously. The total amount of brain substance injected is about
0*25 grm. for each patient. Roux syringes holding 5 c.c. are most suitable for
injecting the vaccine. The needle should be sterilized by dipping it in hot oil
between inoculation of each patient. The inoculation causes no pain, no
general reaction and no local reaction beyond a little redness and itching of the
skin. Patients should be advised against taking alcohol or indulging in any
unnecessary physical exertion during, and for ten days after completion of,
treatment. At the conclusion of the course of inoculations each patient
is given a stamped addressed post-card and requested to inform the Director
of the Institute of the state of his health three months after treatment.

Hydrophobia usually develops before the eighth week after infection in
those who arrive too late for treatment. Patients reported to be alive
three months after completion of treatment are recorded as having been
successfully vaccinated.

Results of Antirabic Treatment in Bagdad.

During the last six months of 1921, 137 patients attended the Central
Laboratory, Bagdad, for antirabic treatment by carbolized vaccine. Up to the
time I left Irak in May, 1922, no case of hydrophobia nor any unpleasant
after-effects of the treatment had occurred.

The work of the Bagdad Pasteur Institute has since been continued by the
Civil Medical Administration, and up to within a few weeks ago only one
death from hydrophobia had occurred in a patient who had undergone
treatment, and that was in the case of a man who refused to allow the
treatment to be completed and so received only four doses of vaccine instead
of fourteen.

Analysis of the records shows that 16 per cent, of the patients were bitten
by animals proved by the laboratory investigation (i.e., by biological test or by
the finding of Negri bodies) to have been rabid at the time of biting, and 10*9
per cent, were bitten by dogs not examined in the laboratory, but certified by
veterinary medical officers to have been rabid. In 26 9 per cent, of the cases
treated there was evidence of rabies in the biting animals, though evidence on
clinical grounds only cannot always be regarded as conclusive.

Of the several methods of prophylactic treatment for rabies, I believe that,
under conditions of tropical climate, the carbolized vaccine of Semple is the
best. The standardized glycerinated virus of Phillips [4], as used in the United
States, seems ideal for treatment in non-tropical countries; but, apart from
the difficulty of obtaining sterile glycerine in the dusty atmosphere of a
tropical town, we found that during the hot weather in Mesopotamia, contact
with glycerine rapidly killed the virus and would, presumably, affect the
potency of the vaccine.

Limitations of Antirabic Treatment.

The object aimed at in antirabic treatment is to confer an active immunity
against rabies before the virus in the saliva of the animal which inflicted the
bite reaches the nerve centres ; when this has been accomplished the failures
rarely exceed 0*8 per cent. On the other hand, should the virus have already

Section of Tropical Diseases and Parasitology

reached the nerve centres by the time the patient has arrived for treatment,
there will be no symptoms to show that this has taken place, but hydrophobia
will set in fourteen days or so afterwards, irrespective of whether the patient
receives treatment or not. Suppose for instance the viru3 reaches the brain
of a bitten person one day before the course of treatment is completed, the
patient will develop hydrophobia fourteen days afterwards and during this
interval he will not have a single symptom to show that the object of
treatment was defeated one day before completion. The explanation of such
a case is clear, since we know that “ street ” virus planted direct on the brain
of a rabbit has an incubation period of at least fourteen days, and that no
treatment subsequent to direct inoculation of the virus on the nerve centres
will prevent the onset of rabies. Now antirabic treatment extends over a
period of fourteen days, and the time occupied by the virus in growing up the
nerve centres is variable and mainly dependent on the proximity of the bite
to the brain. The importance of early treatment is evident, for we have to set
going a race between the growth of a disease and the progress of immunity, in
which immunity is handicapped by disease having a considerable start. If
the disease wins and reaches the vital nerve centres before their defence is
organized, the patient will be in the same hopeless condition as a rabbit would
be had it been inoculated directly upon the brain with street virus.

Cost of Antirabic Treatment.

Provided that there is a well-equipped laboratory already established for
general bacteriological work, the additional outlay required is trivial. The
cost is roughly estimated as follows :—

Initial Expenditure.

Rs.

620
208
360

1,188

Per month.

1 Is.

450
200
14
250

914

The successful breeding of rabbits is an essential item in the maintenance
of a Pasteur Institute. Cut grass and crushed oats or grain must be supplied
daily, and it must be remembered that these animals will not breed during the
hot season in Mesopotamia. The whole year’s supply must, therefore, be
raised in the cool months.

Outlay for instruments and apparatus
Cost of rabbits imported from Kasauli
Cost of rabbit hutches, &c.

Recurring Expenditure.

Salary of 1 assistant surgeon, I.M.D., at, say
,, 1 laboratory attendant ...

,, 1 extra sweeper ...

Charge allowance for the responsible medical officer

REFERENCES.

[1] Semple, “On the Preparation of a Safe and Efficient Antirabic Vaccine.” “Scientific
Memoirs by Officers of the Medical and Sanitary Departments of the Government of India,” No. 44.
[2] “ Third, Fourth, Sixteenth and Nineteenth Annual Reports of the Pasteur Institute of India,
Kasauli,” the last being the Report for 1919: McKendrick, A. G., article—“Rabies,” “ Practice
of Medicine in the Tropics.” Edited by Byam and Archibald, 1921. [3] Hutya and Marek,

“Special Pathology and Therapeutics of Diseases of Domestic Animals,” 1920. [4] Phillips,

“Prophylactic Treatment for Rabies by Means of Standardized Glycerinated Virus,” Journ. of
Immunology , vii, No. 5, September, 1922.

Christopherson : Carriers of Schistosoma

Specimens of (t) Schistosoma boots and of its Snail Carrier ;
(2) the Intermediate Hosts of Schistosoma mansoni Brazil.

Exhibited by J. B. Christopherson, C.B.E., M.D.

I AM showing to-night specimens of: (1) Schistosoma bovis from the
Egyptian Sudan sent by Major L. Danels, of the Veterinary Department,
Sudan, also some specimens of the fresh-water snail which has been found by
CawBton to be a carrier of this trematode in Natal—the vector in the Sudan
has not yet been identified. (2) Also specimens of the intermediary hosts of
Schistosoma mansoni of Brazil , sent by Professor Lutz.

Schistosoma bovis is interesting in view of the fact that Cawston has
recently reported the case of a boy infected by Schistosoma bovis , a conclusion
which F. Milton supports from Cawston’s “ typical ” drawings of the ova (I
have put out Cawston’s drawings for exhibition). The ova have terminal
spines and are longer and narrower than those of Schistosoma haematobium .

Milton suggests that cases of rectal infection with terminal spined ova with¬
out vesical symptoms, such as Low described in Uganda in 1907, and Chester-
man has lately reported from the Belgian Congo, and Clapier from the French
Congo, are cases of infection with Schistosoma bovis and not with Schistosoma
haematobium . In support of this suggestion it has been pointed out that in
Egypt, when Schistosoma haematobium invades the rectum, it rarely does so
without involving the bladder to a greater extent. Schistosoma bovis inhabits
the rectal veins in bovines and equines, and the ova are found in the faeces and
sometimes in the urine of infected animals.

As will be seen from the specimens, Schistosoma bovis is considerably
larger than Schistosoma hcematobium.

With regard to the intermediary host of bovine schistosomes Dr. F. G.
Cawston has incriminated Physopsis africana in Natal (specimens shown.)
Dr. Cawston writes regarding a photograph thrown on the screen : “ This site
of the Magalies Tobacco Factory is well known as a source of bilharzia
infection in the Transvaal. In 1917 I found Physopsis africana on rushes at
the side of the river infested with schistosomes, and Limncea natalmsis
infested with other cercaria.”

The intermediary hosts of the Brazilian Schistosoma mansoni sent by
Professor Lutz are Planorbis olivaceus and Planorbis centimetralis ; he has
given the following information :—

“ Schistosoma haematobium does not as far as we know exist on the
American continent, no doubt due to the absence of a suitable intermediary
host. Schistosoma mansoni is the species of Bilharzia disease found in South
America and in the West Indies ; Cuba is not known to be infected endemically.
The intermediary host of Schistosoma mansoni in the West Indian islands is
Planorbis guadelupensis , which is also the intermediary host of Schistosoma
mansoni in Venezuela. This snail is sparsely found in northern Brazil,
the intermediary hosts of Schistosoma mansoni in Brazil are: (1) Planorbis
olivaceus , and in north Brazil (2) Planorbis centimetralis. Schistosoma mansoni
is found not only in Brazil but also in Dutch Guiana, Venezuela, Colombia
and Peru.”

PROCEEDINGS

OF THE

ROYAL SOCIETY OF MEDICINE

EDITED BY

Sir JOHN Y. W. MacALISTER

UNDER THE DIRECTION OF

THE EDITORIAL COMMITTEE

VOLUME THE SIXTEENTH

SESSION 1922-23

SECTION OF UROLOGY

LONDON

LONGMANS, GREEN & CO., PATERNOSTER ROW

1923

Section of UUologt?

OFFICERS FOR THE SESSION 1922-23.

President —

Sir John W. Thomson-Walker, F.R.C.S.

Vice-Presidents —

W. Langdon Brown, M.D.

Sir Charles Ryall, C.B.E., F.R.C.S.

[Died September, 1922.J

Cyril Nitoh, M.S.

Hon. Secretaries —

Frank S. Kidd, M.Ch.

W. Girling Ball, F.R.C.S.

Other Members of Council —

P. J. Cammidge, M.D.

John Everidge, F.R.C.S.

Sir Thomas Horder, M.D.

J. B. Macalpine, F.R.C.S.

R. Jocelyn Swan, M.S.

Ralph Thompson, Ch.M.

Representative on Library Committee —
Cyril A. R. Nitch, M.S.

Representative on Editorial Committee—

J Swift Joly, F.R.C.S.

SECTION OF I'ROLOGV

CONTENTS.

October 26, 1922.

Sir John Thomson-Walkkr, M.B., F.R.C.S. page

Relation of Calcified Abdominal Glands to Urinary Surgery ... ... 1

November 30, 1922.

W. Rangoon Brown. M.D., F.R.C.P.

The Factors in UVienna ... ... ... ... ... ••• 19

January 25, 1923.

Sir John Thomson-Walkkr, F.R.C.S.

(1) Case of Cyst of Prostate ... ... ... .. ... 31

(2) Case of Myosarcoma of Epididymis ... ... ... ... 31

(3) Case of Aberrant Prostatic Nodule ... ... ... ... 32

Sir John Thomson-Walkkr, F.R.C.S., and F. J. F. Barrington, M,S.

Case of Malakoplakia ... ... ... ... ... ... 32

W. Girling Ball, F.R.C.S.

(1) Necrosis of Kidney following Ligature of Abnormal Renal Vessels ... 34

(2) Specimen showing Transitional-celled Growth of the Kidney ... 35

(8) Absent Right Kidney ; Deformity of Left Ureter ... ... ... 35

W. G. Sutcliffe, F.R.C.S. (Shown by Cyril Nitch. M.S.b

Two Large Calculi removed from the Perinieum of a Male, aged 62, in

Margate Cottage Hospital ... ... ... ... ... 36

L McAlrink, M.B.

Specimens of New Growth of the Pelvis and Kidney ... ... ... 37

Shown by It. Ogikr Ward, F.R.C.S.

A Large Renal Calculus ... ... ... ... ... ... 38

L Swift Joly, F.R.C.S.

Two Cases of Glandular Epispadias ... ... ... ... ... 39

It. H. Jocelyn Swan, O.B.E., M.S.

(1) Multiple Cystic Formation in Lower Pole of Kidney ... ... 41

(2) Pyonephrosis due to the Kinking of the Ureter by Aberrant Renal

Vessels ... ... ... ... ••• ... ... 41

(3) Prostate removed by Prostatectomy ; Weight, 12 oz., or 340 grm. ... 42

Contents

Shown by John Everidge, O.B.E., F.R.C.S. pagk

(1) Specimen showing Interior of the Bladder Six Months after Extensive

Resection for Carcinoma, with Transplantation of the Right Ureter 43

(2) Specimen of Diverticulum of the Bladder ... ... ... 43

A. Clifford Morson, O.B.E., F.R.C.S.

Case of Ectopia Testis ... ... ... ... ... ... 43

Kenneth M. Walker, F.R.C.S.

Serous Cyst of the Kidney... ... ... ... ... ... 45

February 22, 1923.

A. Ralph Thompson, Ch.M., F.R.C.S.

The Propriety of attempting to secure Primary Union after Operations

upon the Bladder and Prostate ... ... ... ... 47

It. Ogier Ward, F.R.C.S.

Case of Air Embolism occurring during Urethroscopy... ... ... 54

March 22, 1923.

J. Swift Jolv, F.R.C.S.

The Operative Treatment of Vesical Diverticula ... ... ... 55

May 31, 1923.

It. H. Jocelyn Swan, O.B.E., M.S.

The Incidence of Malignant Disease in the apparently Benign Enlarge¬
ment of the Prostate ... ... ... ... ... ... 71

June 28, 1923.

Charles Greene Cumston, M.D.

Two Points in connexion with Chronic Nephritis ... ... ... si

Specimen shown by Frank Kidd, M.Ch.

Candle removed from the Bladder of a Male... ... ... ... S4

W. Girling Ball, F.R.C.S.

Pyelogram illustrating the Breaking of Two Shadows into Multiple

Shadows as the Result of Injection of Sodium Bromide ... ... K5

Sir John Thomson-Walker, F.R.C.S.

(1) Case of Malignant Growth of the ltenal Pelvis, with Calculi ... s5

(2) Case of Vesico-urethral Calculus ... ... ... ... NT

The Society does not hold itself in any way responsible for the statements made or
the views put forward in the various papers.

.7 . » 1 i m Balk, Sons A Daniki.hson, Ltd., X8-91, (heat TitehlieM Street, London, W.l

Section of Vlrolo0t>.

President—Sir John Thomson-Walker, F.R.C.S.

Relation of Calcified Abdominal Glands to Urinary Surgery:

PRESIDENT’S ADDRESS.

By Sir John Thomson-Walker, M.B., F.R.C.S.

In the last few years I have examined forty-two cases of urinary disease,
or of supposed urinary disease, where calcified abdominal glands were found
and in which questions of aetiology, of diagnosis and of treatment arose. It
has occurred to me that a discussion of these questions might be of interest to
most of the members of the Section. There are doubtless many angles from
which the subject of calcified abdominal glands may be viewed, but a rapid
review of the literature of the last twenty years does not reveal any widespread
interest in the subject.

We have here the final stage of tuberculous glands in the mesentery, tabes
mesenterica, a disease common in children, and the literature refers almost
exclusively to the active stage of the disease as it occurs in early life. In
children, Still [l] says, the condition is very common but the clinical diagnosis
of tabes mesenterica is much less frequent. In 254 necropsies on tuberculous
children at the Children’s Hospital, Great Ormond Street, tuberculous
mesenteric glands were present in 151, or 59 per cent., while clinically only
forty-six cases were diagnosed in 6,000 or 7,000 patients at the Evelina
Hospital. Corner [2] and Branson [3] in 1905, and Carson [4] in 1918, have
published important articles on the clinical aspect of tabes mesenterica.
Fordyce [5] refers to it in a more general article, and Lund [6] has drawn
attention to it in America. Sims Woodhead [7], Coleman [8], and
MacFadyen and MacConkey [9] have published post-mortem statistics.

From these authors I gather (l) that tuberculous infection of the mesen¬
teric glands is common in children ; (2) that it gives rise to symptoms which
are seldom sufficiently characteristic to permit of a diagnosis unless a palpable
mass is present in the abdomen, or unless, as happens in the late stage, one
or more of the glands become caseous and throw a shadow with the X-rays;

(3) that at this period of life, tuberculosis of these glands, next to that of the
bronchial glands, is the most frequent cause of disseminated tuberculosis ;

(4) that some observers advocate operation upon these glands, but that owing
to the difficulties of diagnosis, operation is only performed if a palpable
swelling is present; (5) that the results of operation at this stage have been
good in the recorded cases.

We will now pass over a period of twenty years or more—the average
age in my forty-two cases was 34 years—and come to the subject I have
set out to discuss, namely, calcified glands in relation to urinary surgery.

])—L T R 1 lOctober 2f>, 1922.

Thomson-Walker: Calcified Abdominal Glands

Here we are dealing with the adult, or at least the cases that I have to bring
before you were with a few exceptions those of adults.

Remarks on Anatomy and Pathology.

Before passing to discuss the clinical side of calcified abdominal glands
from the urological standpoint, I should like to refer briefly to some
points in the anatomical and pathological aspect of the subject. Clinical
investigation showed that one of two groups of glands was affected in the
majority of the cases under my care. One, the more common, lying at the
lower part of the abdomen on the right side (twenty-five in forty-two cases)
and the other less common, towards the upper part of the abdomen on the left
side (ten in forty-two). There were five cases where the shadows lay in the
mid-line over the sacrum, and experience shows that these belong to the same

Fig. 1. — Diagram of superior mesenteric artery with ileocolic groups of lymphatic
glands (after .Jamieson and Dobson).

group as the shadows low down on the right side, bringing the total in this
group up to thirty-two in forty-two cases. There was one case w y here shadows
were present on both right and left sides.

We must refer to the anatomy of the abdominal lymphatics for information
in regard to these groups of glands. Jamieson and Dobson [10] in their
valuable research on the abdominal lymphatics show that the lymphatic
vessels of the intestine from the duodenum to the splenic flexure of the colon,
accompany the branches of the superior mesenteric artery and terminate in the
large glands which lie around the artery at the root of the mesentery. The
lymphatics may be divided into three groups :—

(1) Mesenteric, lying between the layers of the mesentery draining the small
intestine.

(2) Ileocolic, lying behind the parietal peritoneum in the space bounded by
the attachment of the mesentery below and to the left, the transverse meso¬
colon above and the ascending colon to the right (fig. 1).

(3) Mesocolic, lying between the layers of the transverse mesocolon.

Section of Urology

Fig. 2.—Calcified abdominal glands with opaque catheter in ureter.

Fig. 3.—Calcified mesenteric gland.

Thomson-Walker: Calcified Abdominal Glands

Following the branching of the superior mesenteric artery, five subgroups
belonging to the ileocolic group are found, namely: (l) anterior and (2)
posterior ileocolic, (3) appendicular, (4) ileal, (5) right colic.

In my cases the calcified glands lying in the right lower abdomen and
those over the upper part of the sacrum belonged to the anterior and posterior
ileocolic subgroups, while those on the left side of the abdomen belonged to the
mesenteric group. These ileocolic subgroups receive lymphatic vessels from
the terminal portion of the ileum, from the appendix and from the cascum,
while the mesenteric group drain the small intestine. In the majority of my
cases (72‘5 per cent.) the ileocolic subgroups were affected (fig. 2).

These glands, which lay to the left of the spine and high up (23‘8 per cent.),
were assumed to belong to the mesenteric group of glands (fig. 3). In the
operated cases none of the calcified glands either here or in the ileocolic angle
lay near the bowel margin of the mesentery. One or even 2 in. separated the
gland from the bowel, and this was especially noted in those on the left of the
spine, which in some cases lay close to the root of the mesentery, if not
actually in it. It is possible therefore that some of these left-sided glands may
have been glands belonging to the upper ileocolic group near to the origin of
the superior mesenteric artery. These glands, we know from the researches of
Jamieson and Dobson, may receive lymphatics directly from the ileocolic area,
which do not pass through the ileocolic subgroups.

In the cases on which I operated, it was invariably noted that there was no
change in the adjacent bowel, which formed the lymphatic field. In six cases
the appendix had been removed—twice during childhood and three times in
adult life. In two of the adult cases the appendix was certainly normal, and
the operation had been performed for pain, on a mistaken diagnosis. In the
remaining case I removed the appendix myself, at the operation on the calcified
glands. In this case the appendix was fibrous, and the lumen had been
obliterated, a condition noted also by Corner in a similar case. In no case was
there any adhesion of the peritoneum in the neighbourhood of the gland or else¬
where, and there was no sign of tubercle on the peritoneal surface. Except
in three cases, clinical examination in these cases showed no focus of tubercle
elsewhere in the body.

These facts are in accord with the observations of others on tabes
mesenterica in children and with experimental evidence stated by Sidney
Martin [11], which goes to prove that this form of tuberculous infection of the
mesenteric glands is usually an isolated tuberculous infection, and results from
infection from the bowel. In such cases no trace of tuberculous ulceration is
discovered in the bowel, and the bacilli appear to pass through the wall
without producing any gross change. The fibrosis of the appendix already
noted indicates bygone disease, probably of a septic nature. Tuberculous
peritonitis has no direct connexion with this form of glandular infection.

There were three cases in which tuberculosis was present elsewhere in
the body. In these three cases there was tubercle of the kidney and bladder.
Two were boys, aged 13 and 14 years respectively, and one an adult male of
41 years. In the adult the tuberculous infection was widespread, for he
had also suffered from tuberculosis of the lungs and larynx, and there was
tubercular disease of one elbow.

These cases raise the important point of the relation between tuberculous
abdominal glands and renal tuberculosis. Many years ago Brongersma [12 ]
pointed out that tuberculous mediastinal glands were the chief source of
infection in the so-called primary renal tuberculosis. There can be little

Section of Urology

doubt that tabes mesenterica may, in some cases, be the focus of tubercle
from which the kidney is infected, for the condition is an acknowledged
source of disseminated tuberculosis. This is more likely to be the case in the
tabes mesenterica of children than in the calcified glands of the adult. I do
not think, however, that even in children this can be a very frequent source of
renal infection. Tuberculous infection of the mesenteric glands is a very
common condition at this age, but tuberculous disease of the urinary tract does
not occur so frequently in children as in adults. It may be noted that the only
adult in forty cases in which the calcareous mesenteric glands and urinary
tubercle co-existed suffered from tuberculosis of the lungs also. So that
presumably tuberculous mediastinal glands were likewise present.

In the calcified state, the tuberculous process is obsolete, and in the cases
on which I operated I did not find any tuberculous glands apart from the
calcareous glands which I removed. There does not, therefore, seem to me to
be any danger of infection of other parts of the body by tubercle bacilli.

I shall describe a case of calcified abdominal glands and then discuss the
symptoms :—

Miss 0. B., aged 22, had suffered from pain in the left side of the abdomen about
five years ago, the pain coming on when she was tired. After a few months it
disappeared and commenced again suddenly three years ago. As a child she had been
subject to what were called “ bilious attacks.” Ten years ago she had abdominal pain
and the appendix was removed. During the last three years she had been subject to
attacks of severe pain at intervals of about a week, and during the last two months the
pain had been constant, with attacks of more severe pain once or twice a day. The
attack of pain commenced suddenly, usually in the morning, and lasted about three
hours. The pain was very severe and was situated in the left side of the abdomen and
left loin. It ceased suddenly and left no aching or tenderness. The pain sometimes
came on after stooping but often without ascertainable cause. The condition of the
bowel did not affect it. It was relieved by heat and lying still. On two occasions only
had there been vomiting. There had never been any change in the quantity of the
urine and on examination it had always been normal. Menstruation had never been
fully established.

On examination the patient was seen to be well nourished. There was no tenderness
or anything abnormal on palpation of the abdomen. The urine was normal.

X-ray examination showed, in the antero-posterior view, a heavy, somewhat irregular
shadow in the region of the upper pole of the kidney, or suprarenal capsule, alongside the
body of the first lumbar vertebra. In the lateral view the same heavy shadow was
found in front of the bodies of the third and fourth lumbar vertebrae. A bismuth meal
showed delay in the large intestine.

I removed two calcified glands through a paramedian incision to the left of the
umbilicus. They lay in the mesentery near the upper end of its attachment and about
two inches from the bowel margin. The uterus and ovaries were small and undeveloped.
The pain disappeared after the operation and has not re-appeared.

Calcified abdominal glands come into relation with urinary surgery in
diagnosis and in treatment, and I propose to discuss them under these two
headings.

Clinical Symptoms and Diagnosis.

It is a noticeable feature that in only one adult case could a clear history
of childish illness affecting the abdomen be obtained. This patient, aged 44,
suffered from indigestion and remembered that as a child he had suffered from
abdominal pain and constipation. This absence of a definite history of
abdominal trouble during childhood is not surprising when we remember

Thomson-Walker: Calcified Abdominal Glands

the slight symptoms and the difficulties in diagnosis in the great majority of
cases of tabes mesenterica in children. The cardinal symptom of calcified
abdominal glands is pain, but there are certain cases which lead me to believe
that haematuria may also be a symptom.

Pain.

All surgeons will admit that the diagnosis of the cause of obscure abdo¬
minal pain is a matter of some difficulty and the result of the investigation is
sometitbes disappointing. I do not propose to range over the whole subject
of obscure abdominal pain but must confine my remarks to those cases where
pain resembles in some measure that of disease of the urinary tract. The
distribution of pain due to conditions affecting the kidney and ureter is
well known. On the right side of the abdomen two other common pain areas
may give rise to difficulty in diagnosis, namely, gall-bladder and appendix pain.
The position of these also is familiar to all of you.

In a number of the forty-two cases other pathological conditions were
present in addition to the calcified abdominal glands. Thus in seven cases
there was stone in the kidney or ureter, in two there was pyelitis, in three
urinary tuberculosis, and one patient was pregnant. These conditions all
tended to mask the symptoms that might have been due to the glands and
thus confuse the diagnosis. But there were twenty-eight cases in which no
other disease beside the calcified abdominal glands could be detected and the
following notes in regard to symptoms are based upon these cases.

Pain is the chief symptom in calcified abdominal glands and in my cases it
was the prominent feature in twenty-five of the twenty-eight cases. It was
a dull ache in four, very acute pain amounting to abdominal colic in fourteen,
and moderately acute in seven.

In the majority of these pure cases, the pain was a severe colic (fourteen in
twenty-five). The duration might vary from a few minutes to several hours.
The pain commenced suddenly and usually ceased suddenly. In severity it
was comparable to the two chief abdominal colics, namely, renal and biliary
colic, and was much more severe than that of appendicitis. In distribution
it resembled that of moderate renal pain or of renal and ureteral colic in
seventeen cases, of appendicitis in four, and the pain resembled biliary colic
in one. In five the pain area was not defined and in one case there was no pain.
There were certain negative points that helped to distinguish the pain due to
calcified glands from that of renal colic. Movement had practically no effect
in initiating or in increasing the pain. Vomiting, so common in renal and
also in biliary colic, was absent in these cases. There was no retraction of the
testicle and no pain referred to other parts of the body. There was very rarely
any disturbance in the action of the bowels such as might be expected in a case
of appendicitis of long standing.

A tender spot was present in the abdomen in four cases in which the
calcified gland was the only disease present. The tender area lay directly over
the calcified gland and, in all of the cases, lay within the area of tenderness
present in cases of appendicitis, so that this sign tended rather to confuse than
to clear the diagnosis. In one case the calcified gland could be felt as a nodule
and rolled beneath the finger at a point in the line of the ureter above the brim
of the pelvis.

The proportion of cases in which the pain resembled that of renal pain, or
colic, may have been unduly large from the fact that this class of case was the

Section of TJrology

most likely to come under my care. The explanation of the pain is, I think,
to be found in the proximity of the calcified glands to the ureter. The drag or
presence of such a calcareous mass would very easily cause ureteric spasm.
The aching pain in the appendix region in four cases was due to the position
of the calcified gland in this area.

H/EMATURIA.

Blood was present in the urine in microscopic or in naked-eye amount in
six cases in which no disease except the calcified gland could be detected.
One case had severe intermittent haematuria for eight years as the only
symptom. This case may be described in detail as it is of exceptional
interest: —

Miss A., aged 25, the daughter of a doctor, first noticed blood in the urine in 1912
at the age of 17. Since that time there had been intermittent htematuria, the attacks
being brought on by walking or other exertion. For six months she remained
recumbent and saw no blood. At the end of that time she walked and the blood
recurred. She was examined by a number of physicians and surgeons during the
eight years of her illness. The diagnosis of chronic nephritis was first made but this
was abandoned. Bacilluria was found on two or more occasions. On other examinations
the urine was free from organisms. Guinea-pig inoculations were negative. There
were occasional granular casts and some blood casts had been found.

1 examined her in December, 1920. The bladder and ureteric orifices were normal.
A specimen of urine drawn from each kidney was normal. Examination with the
X-rays showed a group of irregular shadows on the right side of the spine opposite
the fifth lumbar vertebra just above the iliac crest. There were no other abnormal
shadows. There was no tenderness at any part of the abdomen and no enlargement of
either kidney. There were no signs of chronic nephritis in the urine or in the general
condition of the patient.

I operated in January, 1921, and removed a chain of calcified glands extending from
the ileo-ctvcal junction for some distance upwards. The appendix was adherent and
fibrous, and was removed. Careful palpation of the kidneys, renal pelvis and ureters
revealed nothing abnormal. The report on the appendix showed that it was the seat of
chronic obliterative inflammation.

In January, 1922, the patient had almost resumed her normal life. She was
getting about and had been taking dancing lessons. There had been no recurrence
of the hiemorrhage.

The laboratory report on the urine showed some red blood cells, some epithelial
squames and a few granular casts. 4

Any statement in regard to the relation of haematuria to calcified abdominal
glands must be purely speculative. In the cases in which this symptom has
been present, and no other cause has been ascertained, removal of the calcareous
masses has been followed by disappearance of the haematuria. One may,
therefore, I think, be justified in suggesting some relation of cause and effect
between the glands and this symptom. The close anatomical relation of the
calcareous glands to the ureter is undoubted. In several cases of calcareous
glands I have found that the passage of a catheter up the ureter has been
arrested at the level of the glands, and although other more rigid or smaller
catheters pass on, I have gained the impression that some pressure or drag
existed at this part. Looking back on cases of obscure haematuria, I can
recall, and I think most urologists must have seen, cases in which the only
cause of the haematuria was some condition outside the ureter, such as an
appendix abscess. One cannot avoid the conclusion, therefore, that calcareous
glands may, by pressure or by dragging on the ureter, be the cause of
haematuria.

Thomson-Walker : Calcified Abdominal Glands

X-ray Diagnosis.

With the complete X-ray examination of obscure abdominal cases that is
now customary, the discovery of calcified glands is becoming much more
common. But, as a result, new difficulties of diagnosis have arisen in the
interpretation of radiograms of the abdominal areas. The shadow thrown by
calcified glands are most likely to be confused with those of stone in the renal
pelvis or ureter, or with gall-stones* There are other less common shadows,
but it is not difficult to differentiate them. A calcified abdominal gland throws
a shadow of varying density and irregular shape that may be situated over
the kidney or gall-bladder areas, or in some abdominal area which a dis¬
placed kidney or gall-bladder may acquire. A kidney stone throws a uni¬
formly dense shadow in the position of the calices, the renal pelvis or the
upper ureter. A gall-stone throws a shadow in the area of the gall-bladder, or
bile ducts, which is not uniformly opaque. There are many exceptions to these
statements, and, moreover, the kidney and gall-bladder areas overlap. It
follows that difficulties arise in recognizing the nature and position of these
shadows.

(1) Position of a Shadow in the Renal and Gall-bladder Areas .—In an
antero-posterior radiogram, the kidney lies in the upper part of the space
bounded by the twelfth rib above, the outer border of the psoas muscle internally,
and the crest of the ilium below. The long axis is obliquely set, so that the
inner border of the upper and lower poles closely approximate the oblique line
of the outer border of the psoas muscle. The renal pelvis lies at the outer
border of the psoas muscle at the level of the transverse process of the second
lumbar vertebra. From this the ureter passes downwards on to the transverse
processes of the third, fourth and fifth lumbar vertebrae. This position is
modified by respiration and position. With full expiration the upper pole
ascends behind the twelfth rib, and with full inspiration the kidney descends
about half the breadth of a vertebral body. In the vertical position there is
a similar descent of the kidney. The shadow of a normal kidney can be
recognized in a radiogram of first quality. The lower pole and inner border
are most evident, and the upper pole less defined. The normal gall-bladder has
been demonstrated on several occasions. In most of the pathological con¬
ditions of the gall-bladder the wall is thickened, and the outline of the gall¬
bladder can be shown in a radiographic plate of proper quality. There is
greater variation in the position of the gall-bladder than in that of the kidney
in normal individuals. It very frequently occupies the space between the
twelfth rib and the outer border of the psoas muscle that is occupied by the
kidney. The shadow is an elongated pear shape with the apex above (Knox).
It lies nearer to the twelfth rib than does the kidney shadow, and its long
axis is not parallel with the outer border of the psoas shadow, as in that of the
kidney shadow, but bisects the angle between the shadow of the twelfth rib
and the outer border of the pyriform gall-bladder, and the outer border of the
psoas shadow is much greater than that below the kidney and the psoas.
Very considerable variation is found in the relation of the gall-bladder to the
bony landmarks, and this is sometimes due to a long and oblique twelfth rib
narrowing the costo-vertebral angle. The gall-bladder shadow is then behind
the twelfth rib and last intercostal space (fig. 4). The long axis may be more
vertical or more transverse. Knox [13] points out that when the gall-bladder
is greatly distended it loses its pear shape and becomes more rounded, so that
the rounded end of the gall-bladder may resemble the lower pole of the kidney,

Section of Urology

but the shape of the whole organ never resembles the shape of the kidney.
It may occupy practically the same area as the kidney, and if only the lower
half of the gall-bladder is seen, it might easily be mistaken for the lower pole
of the kidney. If the outline of the kidney or gall-bladder is shown on a
skiagram, a shadow thrown by a stone in either organ may be localized, or a
shadow thrown by calcareous glands may lie outside these areas, and the
diagnosis can then be made. The stereoscopic method will give valuable
information in regard to the depth of the shadow from the surface, but this is
not sufficiently accurate for the localization of a doubtful shadow in the
kidney or gall-bladder. A calculus in the gall-bladder may lie, as Knox has
shown, at any depth from 3 cm. to 13 cm. from the anterior surface of the
body, this depending on what part of the gall-bladder or ducts it occupies. IJXi0
(2) Size and Shape .—Very large shadows may be thrown by kidney-stones
or gall-stones, but rarely by calcified glands. The larger shadows thrown by

Fig. 4.—Outline of gall-bladder containing gall-stone.

calcified glands are usually groups of shadows and not a single shadow. A
large shadow, if thrown by a kidney-stone, will usually be accompanied by a
large kidney, that is readily palpated in the loin, for in such cases the kidney
is usually dilated with urine or pus. It may be stated, therefore, that when a
large oval or round shadow appears in the loin without urinary symptoms and
the kidney is not palpable, the shadow is more likely to be thrown by a gall¬
stone than by a kidney-stone. There are, however, some remarkable exceptions
to this generalization, where a very large kidney-stone surrounded by a thin
layer of kidney tissue was not palpable in the loin. A stone free in a cavity,
such as the pelvis of the kidney or the gall-bladder, will have a round or
oval shape, which is rarely, if ever, seen in a calcified gland, where the deposit
of salts is not on the surface of a free body but in the irregular necrotic areas
of a diseased tissue, and the outline of which is irregular. Thus, a wedge-
shaped shadow is characteristic of a stone in the renal pelvis, and a branching
shadow is certainly renal. A shadow with irregular outline may be renal or
glandular, but is not biliary.

10 Thomson-Walker: Calcified Abdominal Glands

(3) Density and Uniformity of the Shadow .—A calcified gland or group of
glands has, in the average case, $ density midway between that of a urinary
calculus and that of a gall-stone. It is not so dense as a urinary calculus of
the same size, and it is denser than a gall-stone. There are, however, some
exceptional cases, when a gland may throw a dense shadow comparable in
opacity to a kidney-stone, and occasionally a gall-stone may contain a large
proportion of salts which cast a heavy shadow. Calcified glands throw a
shadow which is irregular in density. When a large shadow is thrown, it has
a mottled appearance that distinguishes it from the shadow of a urinary
calculus or a gall-stone. When a group of shadows are demonstrated, there is
a varying density in different parts of the same shadow and between the
diflerent shadows that distinguish them from urinary calculi. The shadow of
a large calcified gland is not heavier than that thrown by a small gland. The
shadow of a urinary calculus is homogeneous, and the density varies with
the size of the calculus. There is one exception, however, when a flat calculus

Fig. 5.—Gall-stone and pyelography.

is photographed in face. This will give a faint shadow when the outline is that
of a large calculus. In gall-stones the density of the shadow does not
correspond to the size of the calculus. The most characteristic form of gall¬
stone shadow has a central nucleus, a faint, somewhat irregular density in the
body and a dense ring at the periphery. The details of structure and the
regularity of the shadow are almost characteristic. Rarely, as Knox points
out, a renal calculus may throw a shadow which in detail and arrangement
has the character of a gall-stone.

(4) Grouping of Shadoivs .—W r hen a number of shadows are present, the
arrangement of the shadows will conform to some extent to their surroundings.
If calculi lie in a cavity, they will assume more or less completely the shape
of the cavity. Large branching calculi in the kidney throw a shadow which
resembles a cast of an enlarged renal pelvis and branching calices. Shadows of
multiple calculi in the kidney which do not form this perfect cast may
nevertheless with careful study be recognized as occupying the pelvis and

Thomson Walker: Calcified Abdominal Glands

calices. If a wedge-shaped shadow of a pelvic calculus is present, outlying
shadows which occupy calices will radiate outwards from the base of the
wedge. In gall-stones, where all the stones throw a shadow, a peculiar
mosaic or honeycomb pattern is produced, which is unmistakable. Where
only some of the gall-stones are opaque, or where calculi lying in the ducts
are opaque, aline of opacities may be recognized. This line will radiate down¬
wards and outwards from the costo-vertebral angle, and would cross the lines of
radiation of renal calculi. Calcified gland shadows never assume this radiating
or string-like appearance.

(5) The Effect of Respiration and Change of Position .—A stone in an
adherent kidney and one in the gall-ducts is fixed and the shadows will move
little, if at all, with respiration, or change of posture. A calcified gland is
never fixed. The range of movement of the shadow of a stone in the kidney
free from adhesions, of a stone free in the gall-bladder and of a calcified gland,
differ from each other. Of the three the kidney shadow moves least, the gall-

FlO. 8.—Calcified abdominal gland with pyelography.

stone shadow next in extent, and the calcified gland shadow has the greatest
range of movement. Not infrequently the gland shadow will, on a second
exposure, be found to have moved completely out of the field.

The direction of movement is also of importance. Knox has shown, by
making double exposures on the same plate, one in full inspiration and one in
full expiration, that the kidney stone shadow moves downwards and outwards,
while the shadow of a gall-stone free in the gall-bladder moves almost directly
downwards. The shadow of a stone in the common or cystic duct has a less
pronounced displacement in deep inspiration and its line of movement will
approximate that of a kidney stone. The wide excursion of a calcified gland
shadow may be vertical or lateral. Extreme lateral movement is characteristic
of the calcified gland shadow. In one plate the shadows may lie on the spine,
in another over the iliac bone.

(6) Pyelography .—By pyelography the doubtful shadow which may lie
within the kidney area and actually within the limits of the kidney shadow,

Section of Urology

may be proved to lie outside the renal pelvis and calices. The shadow of a
kidney-stone will be engulfed in, or at least be continuous with, the shadow of the
renal pelvis or one of the calices. The shadow which lies apart from the pelvis
or calices is not a renal calculus, and the diagnosis will lie between a gall-stone
(fig. 5) and a calcified gland (figs. 6, 7, 8). Fallacies exist however, even in
this accurate method, and a calcified gland may throw a shadow over the
kidney (fig. 9) and even over a pyelographic shadow of the renal pelvis. A
super-imposed gall-stone may also come within the area of the pelvis and
calices and cause confusion (fig. 10). There are many cases therefore in
which antero-posterior radiography and antero-posterior pyelography will fail
to decide definitely the position of a doubtful shadow. In such cases lateral
radiography and pyelography are invaluable.

(7) Lateral Radiography and Puelorjraphy. —Dr. Knox and the writer have
discussed fully the technique of this method elsewhere and it is unnecessary to

FlG. 9.—Calcified gland in kidney area. Pyelography. (Mr. Clifford Morson’s case.)

revert to these details. In lateral radiography the kidney lies on the sides
of the bodies of the first, second and upper part of the third lumbar vertebra;.
Its shadow cannot be defined, even in a radiogram of the first quality. In a
pyelogram with an opaque catheter in the ureter, the pelvis and abdominal
segment of the ureter is shown (fig. 11). The pelvis throws an elongated oval
shadow tapering at its lower extremity and lying in the shadow of the body of
the second lumbar vertebra. From this the shadows of the calices project to right
and left, that is anteriorly and posteriorly. The upper calices project above
the shadow of the pelvis like horns and the lower calices downwards below the
pelvis. The ureter passes downwards and forwards, crossing the body of
the third lumbar vertebra and reaching the line of the anterior border at the
lower border of the third and the upper border of the fourth lumbar vertebra.

Section of Urology

Fig. 113. —Lateral radiography. Large renal calculi projecting in front of; lumbar

vertebra?,

Thomson-Walker: Calcified Abdominal Glands

In lateral radiography, with the kidney in its normal position and where no
great enlargement of the organ is present, a kidney-stone will throw a shadow
on that of the body of the second lumbar vertebra (fig. 12). A stone
occupying the extreme limit of a calyx may throw a shadow which appears
behind the body of the vertebra, but this is a rare finding and will not give rise
to confusion with any other shadows. The two conditions which may cause
confusion with the shadow of a kidney* stone, are gall-stones and calcified abdo¬
minal glands. The gall-stone shadow lies well in front of the shadow of the
vertebral bodies, usually at the level of the upper three lumbar vertebrae,
but sometimes as low as the fourth lumbar vertebra. The shadows of calcified
abdominal glands may lie as high as the kidney but they are usually lower
down at the level of the third and fourth lumbar vertebrae and they are always
in front of the bodies of the vertebrae.

It should be noted in examining doubtful shadows in the abdomen that
disease may alter the relation of the organs. Thus, a movable kidney has a
wide excursion and in the antero-posterior view the shadow which is .thrown
by a calculus in such a kidney, may be found below the crest of the ilium.
Further, mobility of the kidney may completely change the relation of the
organ to the vertebral bodies in lateral radiography. If a patient with a
movable kidney is turned on the side the organ falls forward and a stone
shadow may be thrown in front of the anterior margin of the bodies of the
vertebrae. To avoid this displacement the lateral view must be taken with
the patient lying on his back. Lateral pyelography with an opaque catheter in
the ureter, will in any case, settle the relation of the doubtful shadow to the
ureter and renal pelvis.

When the kidney is greatly enlarged it will project in front of the spine
and lateral radiography will show a stone shadow T in front of the vertebral
bodies (fig. 13).

Treatment.

In eleven of the forty-two cases of calcified abdominal glands, I operated
and removed the glands. In ten of these cases the operation was planned for
the removal of the glands and in one a calculus was removed from the kidney
and the gland was uncovered in stripping up the ascending colon and removed
at the same time. One other case was operated upon, on my advice, by
Mr. G. H. Percival, of Northampton, who removed three calcareous glands.

The result of the operation in these cases was the disappearance of the pain,
whether it had the form of constant aching or recurrent attacks of colic.
In one case—that of a very stout woman with a large caseous gland near the
upper end of the mesenteric attachment—there were several attacks of acute
pain soon after the operation, but these have now ceased and there has been no
further attack for eighteen months. All the other cases have remained free
from pain since the operation.

In the case of severe recurrent painless heematuria that I have described in
detail, the attacks of haematuria have ceased and the patient has returned
to practically normal life after being an invalid for about eight years.

These results have justified the operation and although the number is not
largo, it is sufficient, I think, to lift the operation out of the purely experimental
or speculative stage. The question as to whether the operation should he
recommended in all cases in which calcified mesenteric glands are discovered
is, however, open to discussion.

Section of Urology

The evil result of the glands in my cases was practically confined to the
causation of pain. At the end-stage of the disease there is no longer any
danger of general dissemination of the tubercle bacillus, nor is there in my
opinion, any probability of infection of the urinary tract. Tuberculous
peritonitis is not a concomitant or a sequel of this condition and adhesions
which might interfere with the action of the bowel or form obstructing bands
do not take place. From the point of view of the possible development of these
complications, therefore, operation need not be considered.

The question is, I think, largely one of the degree of severity of the
symptoms and this will frequently be decided by the patient himself. In
sixteen out of the forty-two cases, operation was suggested and was either
refused or indefinitely postponed by the patient, either owing to the operation
being considered too severe a method of treatment for the symptoms or owing
to a temporary lull in the symptoms.

In children this view is subject to modification. Here there is some
probability of other more recently infected glands being present alongside
the calcareous glands which throw a shadow. Against any general rule of
operation in these cases in children, there is, however, the knowledge that
recovery without operation must take place in the great majority of these cases
without further trouble. The fact that a large number of cases of calcified
abdominal glands are now discovered during routine examination in adults
itself lends support to this conclusion.

Carson, Corner and Branson all advocate operation in children, the two
former authorities from the point of view of local abdominal conditions and the
latter from the fear of general complications. Corner lays it down very
definitely that operation should only be performed in those cases in w’hich
a palpable swelling in the abdomen is detected. This narrows the operation
field to quite a small minority of cases in children.

My view in regard to adults, where the calcareous end-stage erf tabes
mesenterica has been reached, is that operation is only justifiable in those
cases in which symptoms are severe and are proved to be directly due to
the calcified glands. These cases can be selected only after investigation
by thorough modern methods of examination.

REFERENCES.

[1] Goodhakt and Still, “ Diseases of Children,” 1921, p. 477. [2j Corner, Lancet, 1900, ii,

p. 1825. [3J Branson, Med. Chir. Trans., 1905, lxxxviii, p. 349. [4{ Carson, Lancet, 1918,
i, p. 869. [5j Fordyce, lint. Med. Joani., 1909, i, p. 762. [6] Ll ND, Boston Med. and Burr?.
Journ., 1912, clxxii, p. 918. [7 Sims Woodhead, Reports of Laboratory of the Royal College of

Physicians, Edinburgh, 1888. [8j Coleman, Brit. Med. Journ., 1893, ii, p. 740. [9 MacFapyen

and MacConkey, Brit. Med. Jonm., 1903, ii, p. 129. [10] Jamieson and Dobson, Lancet, 1907,

i, p. 1137. 1 11] Martin, “ Allbutt’s System ot Medicine,” iii, p. 660. [12] B RONoerkma. First

Congress, Internat. Assoc, of Urology, Paris, 1908, p. 551. [13] KNOX, Arch, of Badioloyy and

Elect ro - the ra />//, 1919 .

D—Cr la

Section of 'Urology.

President—Sir John Thomson-Walker, F.R.C.S.

The Factors in Uraemia.

By W. Langdon Brown, M.D., F.R.C.P.

The conventional view of uraemia may, I think, be fairly expressed as
follows: In nephritis, some toxin or toxins may, by acting upon the central
nervous system, lead to one or more of the following groups of symptoms:
(1) Cerebral, (2) respiratory, (3) gastro-intestinal, (4) cutaneous, (5) muscular.

In my opinion it is possible to simplify the problem by eliminating certain
of these groups. Thus, the gastro-intestinal symptoms of nausea, vomiting
and diarrhoea, may be due to an attempt to find alternative channels of
excretion. Eight grm. of nitrogen can be excreted by the bowel daily,
whereas the skin cannot get rid of more than 3 grm. (Von Noorden). No doubt
this is irritating to the bowel, and in certain cases it is clear that organic
lesions develop such as ulceration and catarrhal or 41 diphtheritic ” colitis,
which in themselves would tend to produce diarrhoea. It is true that toxic
irritation of the medulla can of itself produce vomiting, but the presence of urea
in the vomit in greater concentration than in the blood, is suggestive of a
vicarious method of excretion. Thus Canti has found urea in the blood to be
0’3 per cent., and in the vomit 0*6 per cent, in a severe case, Again, rashes
and intense pruritus are very probably symptomatic of an attempt to excrete
toxins by the skin. In a case of uraemia with an intense erythema, under my
care, the blood, in spite of continuous vomiting, contained 0‘4 per cent, of urea.
Again, the immediate cause of pruritus is the setting up of osmotic currents in
the lymph between the prickle cells; and excess of sodium chloride there
might be expected to excite it. The contractions, local pareses and myoclonic
movements have also been referred to a local intoxication of the muscles
and not to a central cause [1].

Such a view would restrict the term uraemic syndrome to the cerebral and
respiratory manifestations. We may next inquire into the evidence of a toxic
cause for these manifestations. Roger [2] describes eleven different toxins in
normal urine, several of which produce uraemic symptoms, such as coma and
convulsions. Canti [3] has shown that urea retention occurs in uraemia, and
has been able to correlate the degree of urea retention with the prognosis.
But it is difficult to refer uraemia to the retention of a normal constituent of
urine since Ascoli showed that total suppression, such as follows complete

Mh— U 1 [November 30, 1922.

Langdon Brown : The Factors in Urcemia

obstruction to the ureters, does not lead to the characteristic features of
uremia. Just as hydronephrosis follows an incomplete or intermittent
obstruction to the ureter, while atrophy of the kidney is more likely to
follow complete obstruction, so uraemia is more apt to follow incomplete
failure of excretion, while complete failure produces the syndrome termed
“ urinaemia.” According to Ascoli, severe urinaemia in man is chiefly
manifested by bodily weakness and languor which are often apparent before
any other symptoms, but it generally leads to progressive mentaLweakness and
exhaustion, often terminating with great suddenness. In urinaemia, how¬
ever, most of the prominent symptoms of uraemia are lacking, especially the
severe and acute mental disturbances, the sudden amaurosis, and the epileptic
phenomena in general. Only in occasional cases do the symptoms resemble
uraemia. Nor has any better success attended the attempts to explain uraemia
as due to the decomposition products or the antecedents of such constituents.
If we are going to attribute all the manifestations of uraemia to a toxic cause,
its association with partial—rather than total—failure of secretion suggests
(1) that the process of its development is a gradual one, and that total
suppression is too rapidly fatal for this to occur: (2) that incomplete excretion
may lead to altered metabolism so that abnormal toxic products are formed.
On this view uraemia would be a disease of metabolism resulting from damaged
kidneys. In the same way, diabetic coma is not the direct result of glycosuria
but of the altered metabolism produced by diabetes. Golla has suggested that
such altered metabolism leads to the formation of trimethylamine, which he
has found to be increased ten-fold in the blood in uraemia, and he is inclined
to attribute the whole of the syndrome to this substance. It is true that the
cerebro-spinal fluid in uraemia will develop a smell of trimethylamine, but for
reasons which will appear later I find difficulty in accepting this view in toto.

That toxins have a selective effect on nervous tissues is well illustrated
in diphtheritic paralysis and plumbism, among exogenous poisons, and that
endogenous poisons may have a similar action is suggested by the combination
of cirrhosis of the liver with progressive degeneration of the lenticular nucleus
(Wilson’s disease) where the affected nervous structures become bile-stained.
One poison may, by its selective action on different tissues, produce very
different symptoms: thus alcoholism may be associated with delirium tremens,
multiple peripheral neuritis, cirrhosis of the liver and cardio-vascular degenera¬
tion. It may be argued that other conditions determine which of these
manifestations occurs ; thus delirium tremens follows too rapid reduction of the
dose of alcohol when it was become an acquired need, while cirrhosis only
develops when alcohol has set up a preceding gastritis, in which other factors
such as pyorrhoea may play a part. Similarly it is quite possible to explain
uraemia as due to one poison acting on different parts of the central nervous
system according to varying conditions. And yet it is a striking fact that the
different manifestations appear under very different conditions and have a
widely different significance.

Let us consider next the conditions under which they arise.
f Is nephritis a necessary precursor to uraemia ? Using the term nephritis in
the strict sense, the answer is, “ no ”—for a toxaemic kidney may, at any rate,
A give rise to convulsions and amaurosis, although it apparently never causes
paroxysmal dyspnoea. By a toxaemic kidney we mean a kidney the tubules
of which are suffering from degenerative but not inflammatory changes, the
result of some chemical poison. Although severely damaged for a time, such
a kidney is, nevertheless, capable of complete recovery. The commonest cause

Section of Urology

of toxaemic kidney is bacterial toxaemia. Febrile albuminuria associated with
cloudy swelling of the kidney should be referred to this group. But this is
a mild form of the condition. “ More potent are certain exogenous and
endogenous poisons. Mercurial salts, arsenic and cantharides are important
causes clinically, while uranium and bichromate salts are frequently used in
the experimental production of this condition. Jaundice and diabetes mellitus
are not uncommon causes, but the outstanding example of the endogenous
group is the toxaemia of pregnancy ” (Geoffrey Evans). It involves no cardiac
hypertrophy or gross arterial disease. There is cloudy swelling, vacuolation
and desquamation of the epithelium of the convoluted tubules, there may be
fatty degeneration, and in more severe cases focal or diffuse necrosis. The
glomeruli, the loops of Henle, and the collecting tubules show little damage.
There is oedema of the interstitial tissue but no small cell infiltration except as
a secondary reaction to necrosis. Similar changes may be found in other
organs, especially the liver. The condition may give rise to oedema and intense
proteinuria, like acute nephritis, but distinguishable, during life, by the follow¬
ing tests. The urine rarely contains polymorph leucocytes, as is usual in
acute nephritis. The protein in the urine of acute nephritis shows an albumin
to globulin ratio of 6 to 1, but in toxaemic kidney, of 2 to 1. The output of
diastase in the urine is low in nephritis but high in toxaemic kidney. The urea
in the blood is raised in many forms of nephritis but not in toxaemic kidney,
while the blood sugar tends to rise in the former but not in the latter, for in
nephritis the glomeruli are less permeable, and in toxaemic kidney they are too
permeable (Mackenzie Wallis). The failure to recognize toxaemic kidney has
led to some confusion, which has affected prognosis. The outlook in toxaemic
kidney is better than in nephritis of apparently equal severity, even when
accompanied hy unemic convulsions. Again, the macroscopic appearances of a
toxaemic, kidney, post mortem, have been mistaken for those of chronic
parenchymatous nephritis. But the distinction between the two conditions
can readily be made by the above biochemical tests. Apparently, then,
uraemia may occur with a temporary and non-inflammatory lesion of the
kidney, which is not characterized by a retention of toxins, but by an undue
permeability of the kidney to anything which the blood presents to it.

Next, as to acute nephritis, interest in which was much stimulated by
the widespread epidemic which occurred in the war [4] [5]. This is not the
place to discuss its causation, but it may safely be asserted that the condition
was a true nephritis, and that some of the apparent points of difference between
it and the acute nephritis of civil practice were due to previous observations on
the latter having been inaccurate or defective. Thus polymorph leucocytes
which were found in the urine of war nephritis have since been noted in
ordinary acute nephritis. Dunn found the glomerular tufts were obviously
empty of blood in war nephritis, and Andrewes has since found this to be true
of ordinary acute nephritis. Blood may be extravasated between the layers of
Bowman’s capsule, but the glomerular vessels are empty. The frequent onset
with bronchitis and dyspnoea at first seemed a point of distinction, but Dunn
found that these were due to fibrinous exudate into the bronchi, desquamation
of the endothelium and minute thrombi in the pulmonary capillaries. He
regarded the lungs as the primary site of invasion, the nephritis being
secondary. In the same way, the sore throat preceding scarlatinal nephritis
cannot be regarded as differentiating this from other types of acute nephritis.
Renal permeability tests in the war cases pointed to true nephritis in such
features as diminished diastase output, chloride retention, deficient urea con-

Langdon Brown: The Factors in TJrsemia

centration in the urine and increase of the urea in the blood, though not all
these points were present in every case investigated. The interest of this
epidemic for our present discussion is that here we have a true acute
nephritis, with a low mortality-rate, while only about 7 per cent, of the cases
passed into a stage of chronic nephritis (Tremoli&res and Caussade), so that
we have an opportunity of studying uraemic manifestations in a benign type
of the disease. In a series of 166 cases investigated by me the only uraemic
manifestion was that of convulsions in seven cases, i.e., 4 per cent., the same pro¬
portion as that found by other observers. All these seven cases recovered after
venesection. Apathy, slight drowsiness, subnormal temperature with headache
and nausea were the most usual uraemic symptoms according to Bradford.
Vomiting occurred but was not usually so severe as in civil practice. Bradford
noted transitory acute mania after a convulsion in one case, and amaurosis
in another, but he states that uraemic asthma did not occur. Certainly I never
saw it in my series. Canti did not find the urea in the cerebro-spinal fluid so
much increased as in ordinary cases of uraBmia. Pains in the limbs were
emphasized by several observers. It will be noted that apart from convulsions
the manifestations of uraemia in war nephritis were slight, and that the con¬
vulsions were not of evil prognosis.

Another form of acute nephritis is that known as focal embolic nephritis,
as seen in infective endocarditis. The starting point of this lesion is not merely
a chemical toxin, but the deposit of actual infective material in the kidney by
embolism. The septic element thus predominating, it is not surprising that
ordinary uraemia is comparatively uncommon in this form. Thus, I have never
personally seen uraemic convulsions in this type, while life is seldom prolonged
sufficiently for the uraemic manifestations associated with more chronic forms
of nephritis to develop.

In chronic parenchymatous nephritis, whether in the form of large white
kidney or the secondarily contracted form, all types of uraemic symptoms are
comparatively common. But perhaps this is the condition under which
paroxysmal dyspnoea is most apt to occur. When the interstitial tissue is
largely affected, and the blood-pressure becomes higher, the cerebral manifesta¬
tions other than convulsions are most likely to declare themselves. When the
kidney lesion is due to an ascending infection of the ureters, or to obstruction
of the outflow of urine, or to both of these conditions combined, the symptoms
are those of urinaemia rather than those of uraemia. Sepsis may, however,
play a part in inducing typical uraemia by throwing sufficient kidney substance
out of action. Thus in a recent case of glycosuria with persistent Bacillus
colt infection, in a woman aged 60, uraemic convulsions developed. Soon after
this the right kidney became swollen and tender, and there was a copious dis¬
charge of pus in the urine, after which there were no more convulsions.
Some three weeks later the patient became comatose and died. The occurrence
of an acute pyelitis in a chronically infected kidney appeared to determine the
onset of uraemia. In another case, an elderly man who had recovered from
a severe prostatectomy some four months previously, rapidly became uraemic
with haemorrhagic diarrhoea, when he developed an abscess in his epididymis.
Another factor which may precipitate uraemia in chronic interstitial nephritis
is inability to absorb sufficient water to keep up an adequate blood volume
when the kidney is incapable of excreting a concentrated urine. This I have
seen occur in new growth of the oesophagus and stomach.

In contrast to these various conditions of the kidney in which uraemia
or urinaemia may occur, I should like briefly to refer to one in which no

Section of Urology

such symptoms are to be expected. This is “leaky kidney,” by which I mean
a kidney that has suffered from an earlier but non-progressive lesion. It allows
proteins to escape from the blood into the urine, but it does not retain material
which it ought to excrete, nor is it associated with cardio-vascular changes.
The ratio of albumin to globulin may be 2 to 1, as in toxaemic kidney, and
unlike nephritis, where it is, as I have said, 6 to 1. The reactions to renal
permeability tests are all normal, and the principal chemical difference between
leaky and toxaBmic kidney is that although the diastase output is normal in
leaky kidney, i.e., 10 to 33 units, it is never raised above normal, as in
tox®mic kidney (Mackenzie Wallis). The clinical distinction is that toxaemic
kidney is an acute, while leaky kidney is a chronic condition. The
recognition of leaky kidney is important, as it is compatible with normal
health and runs a favourable course, despite the large amount of protein
in the urine. It is not the material which escapes, but the material which
is retained, that leads up to uraemia.

Having thus briefly considered the conditions which do or do not
produce uraemia, I will proceed to analyse the significance of the principal
factors which I should include in the syndrome, and state my view on their
causation.

(1) Convulsions and Amaurosis . — I have already said that the most
dramatic manifestation of uraemia, namely convulsions, may develop in quite
recent cases, and complete recovery may occur, not only from the uraBmia but
from the nephritis. Convulsions may be the first sign of a kidney lesion, as in
the case of a man I saw who more than ten years ago had severe convulsions
when apparently in normal health, except for a septic gunshot wound of one
eye. His urine was found to be loaded with albumin, and he had many retinal
hoBmorrhages in the other eye. Yet the whole condition cleared up after ex¬
cision of the wounded eye. His retina is normal, he has no albuminuria, no
cardiac hypertrophy, and no rise of blood-pressure. There was some reduction
in his urinary diaatase after other signs had cleared up, but even this is now
normal. This has not been my experience with other uraemic manifestations,
and such cases suggest that the toxin causing convulsions is not the same as
those producing other uraemic symptoms. It may be compared to that causing
the clinical condition called eclampsia, which, again, may come on very sud¬
denly, and from which recovery may be complete. Now eclampsia has been
referred to the effect of a toxin acting on the liver; possibly uraemic con¬
vulsions are also thus produced. Amaurosis may occur under the same con¬
ditions as convulsions, such as eclampsia, toxaemic kidney, and acute nephritis.
Complete recovery is possible in cases showing both these symptoms, and I am
inclined to attribute them, therefore, to the same cause. The important point
to note is that these symptoms may occur under conditions in which the kidney
is not retaining toxins.

(2) Paroxysmal Dyspnosa .—It has been established by several observers
that acidosis may occur in nephritis from the failure of the kidney to excrete
acid sodium phosphate. Such acidosis may reach a higher level in nephritis
than in any other condition [6]. Now, when acid is retained in this way, the
body will attempt to compensate for it by excreting more C0 2 through the
lungs. The normal changes in the alveolar air during digestion show this very
well [7] ; during the time that the acid gastric juice is being secreted into the
stomach, the fall of hydrogen-ion concentration in the blood leads to diminished
stimulation of the respiratory centre—consequently CO* tends to accumulate in
the pulmonary alveoli. During the secretion of the alkaline pancreatic juice,

Langdon Brown: The Factors in Uraemia

the hydrogen-ion concentration of the blood rises again, stimulating the
respiratory centre to renewed effort, so that CO 2 is washed out from the lungs,
and the alveolar air is found to contain less. In health the kidney and the
lung can insure between them a fairly constant hydrogen-ion concentration in
the blood—any change is soon compensated for. But when the kidney fails
to excrete acid sodium phosphate the hydrogen-ion concentration of the blood
must rise, and the respiratory centre will be stimulated to compensate for this.
The increased respiratory effort in time becomes manifest, and there is obvious
dyspnoea. Yet even the marked dyspnoea which constitutes uraemic asthma
may prove inadequate to compensate for the acidosis. This unchecked
acidosis poisons the heart muscle, cardiac dilatation ensues and pulmonary
oedema follows. For it is a familiar clinical observation that uraemic
asthma may terminate in pulmonary oedema. It is true that heart failure
often excites dyspnoea in nephritis without failure to excrete acid sodium
phosphate. But I would restrict the term uraemic asthma” to paroxysmal
dyspnoea occurring in nephritis before signs of heart failure develop. 1

Increased ammonia formation may be looked upon as simply an attempt to
combat this acidosis. It has been held responsible for uraemic convulsions,
but this is unlikely, as ammonia formation may reach a high level in other con¬
ditions without causing convulsions. The three compensatory mechanisms
for acidosis are hyperpncea, protective ammonia formation, and increased
output of acid in the urine; in nephritis the last method is interfered with
and the other two become inadequate. It might be suggested that drowsiness
and coma could be attributed to acidosis, on the analogy of diabetic coma,

but Hurtlev and Trevan have shown that these symptoms in diabetes are

con

due to the enolic group ^ in diacetic acid, and not to acidosis at all.

They are produced as readily by sodium diacetate as by diacetic acid. It would
appear, therefore, that paroxysmal dyspnoea stands apart from the other
symptoms in the syndrome ; in being directly due to acidosis from failure to
excrete acid sodium phosphate. That it occurs in paroxysms is presumably
due to the temporary diminution of the acidosis which the increased respira¬
tory effort can achieve by removing more C0 2 from the blood. The way in
which this paroxysmal dyspnoea may be replaced by Cheyne-Stokes respiration
also suggests this.

(3) Headache , drowsiness , coma , hemiplegia , insomnia and acute mental
changes , such as mania or delusional insanity , which usually occur in chronic
lesions of the kidney, although they sometimes manifest themselves with great
rapidity. This third group of “ uraemic ” manifestations appears to be chiefly
associated with kidney lesions when vascular changes are paramount. Geoffrey
Evans [8] has shown by his histological studies that the essential glomerular
lesion in chronic interstitial nephritis is inflammatory in origin. His general
conception of nephritis may be summarized thus: The kidney may be affected
by pathogenic agents of varying kind and intensity, all of which, however, are
capable of inducing active inflammatory reaction in the tissues they attack,
whether epithelial or vascular. When acute, the epithelial reaction dominates
the picture ; when chronic, both epithelial and vascular changes co-exist; in
the very chronic, only the vessels suffer, the pathogenic agent being too feeble
to evoke reaction in the epithelial tissues, or these tissues being too feeble

l l nsts<rij>t .—In the discussion the importance of heart failure without acidosis, in the
causation of this dyspnoea, was emphasized.—W. L. H.

Section of Urology

to react, they simply atrophy or degenerate. From this point of view neither
vascular nor renal disease is to be regarded as the cause of the other, but both
are due to the action of the same toxic agent. According to this author, diffuse
hyperplastic sclerosis is more common in the kidney than in any other organ ; it
is not found in other organs unless present in the kidney or spleen ; it is always
most marked in these organs, and it is not found in its typical development in
the heart, lung, or skeletal muscles. In this connexion it may be noted that
the recognized association between chronic interstitial nephritis and cerebral
haemorrhage has been attributed, and I think rightly, to the simultaneous
occurrence of similar changes in the vessels of the kidney and the brain. But
I think we can now see that this association between vascular changes in
these two organs is not limited to cerebral haemorrhage. We have more
recently recognized the extraordinary impermeability of the normal endothe¬
lium of the cerebral vessels to toxins. In his study of a case of carbon
monoxide poisoning, Mott was able to show that the later cerebral effects
were due to fatty degeneration in the capillary endothelium of the brain,
following its deprivation of oxygen. In consequence of this vascular
change multiple extravasations of blood occurred. Without postulating the
constant presence of such a gross lesion as this, we can see how the active
inflammatory changes in the cerebral vessels in chronic interstitial nephritis
must seriously diminish their impermeability to toxins, and it is to this that the
poisoning of the brain must be referred. Often, however, actual vascular lesions
such as punctiform haemorrhages are found in the brain, post mortem, when
clinically the case appeared to be one of uraemia.

I should agree with Evans that the difference between diffuse hyperplastic
sclerosis and senile arteriosclerosis is one of physiological age response, as
expressed both in the kidney and in the brain. With the first are
associated cerebral haemorrhage and uraemia, with the other cerebral
thrombosis and a “ contraction of the sphere of mental and bodily activity ”
(Allbutt).

Canti has arrived at somewhat similar conclusions by a different route, and
I am indebted to him for kindly putting at my disposal his, as yet unpublished,
recent work. Since 1913 he has carried out about 300 observations on urea
retention by the hypobromite method. He found the distribution of urea in
the body fluids, e.g., the blood, cerebro-spinal fluid, pleural effusion, pericardial
fluid, ascitic fluid and oedema fluid, obtained in Southey’s tubes, to be always
approximately uniform in any one case. The rate at which equilibrium takes
place was demonstrated by an experiment carried out in conjunction with
Hurtley and Trevan. A dog was anaesthetized and cannulas were inserted
into the sub-cerebellar cisterna and into an artery. A large quantity of urea
was then injected intravenously and samples of blood and cerebro-spinal fluid
were collected every thirty seconds. At first urea was found in abundance in
the arterial blood while that in the cerebro-spinal fluid was normal, but in the
course of a very few minutes the urea was found in equal concentration in both.
Observations on the cerebro-spinal fluid may be therefore taken as indicating
the general urea concentration in the tissue fluids. Normally this is 0*02
to 0‘05 per cent., though when death from any cause is approaching this
figure may be somewhat raised. To eliminate this factor he only accepted
percentages above 0’2 per cent, as showing definite urea retention. Taking
ninety-six cases in which uraemia was positively diagnosed clinically, sixty
showed urea retention and thirty-six did not. He seldom found serious urea
retention in cases which recovered, and all cases with a urea content of

Langdon Brown: The Factors in Uraemia

0*3 per cent, or more in the cerebro-spinal fluid were fatal. The highest figure
he obtained was 0’88 per cent. Of cases diagnosed as uraemia in chronic
nephritis, two classes could be distinguished. The first and larger class
showed urea retention—all of these died. The second showed no retention;
some of these recovered, at any rate for the time being, while all of the fatal
cases in this class showed cerebral lesions such as haemorrhages, embolism or
thrombosis. Cases diagnosed as uraemia with the arteriosclerotic type of
kidney also fell into two classes. Here the first class, showing urea retention,
was the smaller; the retention was not extreme, rarely above 0*3 per cent.,
but the cases were all fatal. The second class, without urea retention, was the
larger; some of these survived for the time being, the rest died. He considers
that many of these cases without urea retention showed signs of cardiac
failure, and that treatment directed towards combating this was the only thing
which helped them at all. If the uraemic syndrome is to be regarded as
essentially toxic, it follows that such cases must be excluded.

One criticism I made to him on these observations was that the hypo-
bromite method evolves nitrogen from other nitrogenous bodies besides urea,
so that I would prefer to speak of retention of non-protein nitrogen. Although
urea would be the most abundant constituent, it need not be the toxic one,
nor, indeed, is it likely to be. He then compared the yield to the hypobromite
test with that given by the urease test, which would show the amount of urea
only, without the other forms of non-protein nitrogen. The figures he obtained
in one case of mine were very striking. The blood urea by the urease test was
0*4 per cent. Analysis of the cerebro-spinal fluid gave 0*69 per cent, by the
hypobromite method, and 0*45 per cent, by the urease method. The amount
of “ unknown nitrogen ” was, therefore, greatly raised, both proportionately and
absolutely, being 0*24 per cent. Expressed proportionately this was nearly
35 per cent, of the total instead of the usual figure of about 8 per cent. And
this is typical of other cases. I would suggest that it is this development of
non-protein nitrogen other than urea which is the real toxic element in these
cases. For urea is not a toxic substance.

I consider that Canti has shown the existence of two definite groups of
cases which have not been discriminated hitherto : one in which a chemical
factor can be detected—azotaemia, in the widest sense ; and another in which
cardio-vascular conditions, particularly cerebral-vascular lesions, are responsible.
I think that grouping together a large number of symptoms under the
term of “ uraemic syndrome,” and trying to find one toxin responsible for them
all have tended to obscure the issue and to discourage attempts at detailed
correlation of symptoms with their actual causes.

I would express my position somewhat as follows: (1) The intense action
of a toxin may produce a profound degenerative or inflammatory change in the
renal epithelium, which may be associated with convulsions. As cerebral
and renal vessels are liable to similar lesions it may well be that these
convulsions are due to exudation, even of blood, from the cerebral vessels. In the
more chronic cases punctiform haemorrhages have been found in the brain in
patients dying with convulsions. From the existence of similar changes in the
liver and from the analogy of eclampsia, it is at least possible that the liver is
as much responsible for this symptom as the kidney. The work of the kidney
is elimination, and in toxaemic kidney this at least is not impaired. Part of
the work of the liver, on the other hand, is detoxication, which would be
seriously impaired by damage to the hepatic cells. Convulsions and amaurosis
are the only “ uraemic ” manifestations from which complete recovery is
possible.

Section of Urology

(2) The retention of acid salts by a damaged kidney can produce such
a high grade of acidosis that marked dyspnoea, generally paroxysmal, may
result. This is most likely to occur in more chronic lesions of the tubules.

(3) In the most chronic inflammatory vascular lesions of the kidneys
similar changes take place in the cerebral vessels, which allow a soaking
into the brain of toxins, probably amines other than urea, which produce
headache, drowsiness, coma and various less common cerebral symptoms.
Grosser vascular lesions such as haemorrhages or thromboses may also result.
And Nordman [9] has found the characteristic lesions of chronic meningitis in
chronic uraemia.

(4) Severe obstruction to the outflow, on the other hand, is more likely to
lead to symptoms of urinaemia, as defined by Ascoli. The clear-cut features
of the different types are often blurred, however, by the co-existence of several
lesions. Thus, the urinaBmia of prostatic origin is very likely to be complicated
by vascular changes as well, considering the age at which prostatic troubles
occur, while the septic complications to which nephritics are so prone are apt
to alter the manifestations of uraemia at any age.

(5) Some cases of apparent uraemia are really cases of cardiac failure and
only respond to treatment for this. It would therefore appear that even
using the term in a restricted sense, the uraemic syndrome may be due to
at least two different chqmical substances, one nitrogenous and the other
non-nitrogenous, in addition to vascular lesions and septic complications.

REFERENCES.

r lj Brelet, Gaz. des Hop., September 17, 1912, p. 1477. [2] Roger, “ La MSdecine,” Paris,

1920, p. 232. [3J Canti, Lancet , February 12, 1916, p. 344. [4] LANGDON Brown, Medical

Research Committee Reports, May 16,1917. [5] Maclean, Medical Research Committee Reports,
1919, No. 43. [6] Mackenzie Wallis, Brit. Med. Joum ., 1920, ii, p. 73. [7] Dodds, Joum.

Physiol ., 1921, liv, p. 342. [S] Evans, Geoffrey, Quart. Joum. Med., 1921, xiv, p. 215.

9j Nordman, quoted by Mestrezat, “Le Liquide Cephalo-rachidien,” Paris, 1912, p. 697.

DISCUSSION.

Dr. J. R. Marrack said he considered that paroxysmal dyspnoea in nephritis was
due not to acidosis, but to vascular disturbances. In the most severe cases of
dyspnoea he had seen, the plasma bicarbonate had been normal and the plasma
reaction normal or on the alkaline side; the blood-pressure of these patients had
been very high, and in some the renal efficiency had been only moderately reduced.
On the other hand, hyperpncea might not be striking, even in cases of extreme
acidosis, with plasma bicarbonate of 20 or under, and when it occurred it was
a deep and undistressed breathing, very different from the violent efforts of
dyspnoea. Other disturbances usually classed as uraemia occurred in patients with
high blood-pressure and fair renal efficiency, with no evidence of retention ;
among such disturbances were mental changes, such as delusions of persecution,
transient unconsciousness, and paralyses, headache and vomiting. Apart, however,
from these cases, which appeared to be explained by vascular changes, the majority
of cases of uraemia had high blood urea, and the obvious explanation of the con¬
dition was that it was caused by retention of some poisonous products of meta¬
bolism. However in occasional cases, which could be classed in the vascular group,
coma and convulsions occurred although the blood urea w r as normal and the renal
function only moderately impaired. In contrast with these there were others with
extreme renal impairment, blood urea up to 0‘6 per cent., high inorganic phosphates,
uncompensated acidosis, altered distribution of Cl between plasma and tissue;

Langdon Brown: The Factors in Uraemia

fluids, great change in plasma proteins, and yet no evidence of uraemia—or, at most,
drowsiness and headache. It was difficult to reconcile such cases with an ex¬
planation of uraemia as due to retention, or to any of these changes. It was pos¬
sible that some of the changes were compensatory, and that uraemia in the cases
with no evidence of retention, was due to slight retention or change of distribution,
without the compensatory change. In some cases uramia, especially muscular
twitchings, appeared with reduction of plasma Ca, but the plasma Ca was not
reduced in all cases of urtemia.

Dr. G. A. HARRISON said that acidaemia could not be an important factor in
the causation of renal dyspnoea, because renal dyspnoea might occur in the absence
of acidaemia, and vice versa. Professor Fraser 1 and his collaborators had recently
published a paper demonstrating this point. They had determined the hydrogen -
ion concentration of the arterial blood by the colorimetric method of Dale and
Evans. A case of 44 Lewis’s dyspnoea,” under Sir Charlton Briscoe, had been
similarly investigated at King’s College Hospital by Professor Lovatt Evans, and was
interesting in this connexion. This patient had marked hyperpnoea with Cheyne-
Stokes breathing and no cyanosis. When first examined he was on large doses
of alkali and his blood was alkaline (Ph 7*81). Later the alkali was discontinued.
His dyspnoea very definitely improved, although his blood was now slightly more acid
than normal (Ph 7*50). His systolic blood-pressure varied between 148 and
194 mm. Hg. He had slight albuminuria, and very occasionally granular casts were
found. The Wassermann reaction was strongly positive. He finally died in typical
uraemia. Post mortem, the kidneys were granular and contracted, weighing 2 and
2f oz. respectively. Dr. P. P. Laidlaw and Dr. E. ff. Creed had kindly examined
the sections which they had regarded as characteristic of arteriosclerotic kidneys.
There was also slight fibrosis of the arterioles of the medulla oblongata. This case
therefore provided some evidence in favour of the view that renal dyspnoea was due
to disease of the vessels supplying the respiratory centre.

Dr. F. Parkes Weber alluded to the apparently mechanical factor in the
causation of certain cases of uraemic convulsions. Young adult patients were
occasionally met with in whom universal renal dropsy, commencing acutely, lasted
for months and months, until they were regarded as almost hopeless cases of “ large
white kidney.” They required repeated tapping of ascites, hydrothorax and sub¬
cutaneous oedema of the lower extremities. At last the dropsy might completely
disappear, almost spontaneously, within a week or so, owing to a regular “ diuretic
crisis.” The patient could get up and resume active life, though more or less
albuminuria persisted. Some of these cases, but not all , 2 were connected with early
syphilis a (possibly even before or without the occurrence of secondary syphilitic
cutaneous manifestations). Vomiting and headache were sometimes present, but one
of the greatest dangers was the onset of urjemic convulsions, which in this class of
case was likely to be followed by death. It seemed as if the uraemic convulsions
in such cases, when they occurred, were due to a kind of overflow of the dropsical
effusions from the subcutaneous tissues, peritoneum, and pleurae, into the cerebro¬
spinal system, thus giving rise to excess of cerebro-spinal fluid (and possibly to oedema
of the meninges and brain itself) and cerebral anaemia by compression of the brain.
This view was certainly supported by the modern teaching of F. Volhard, in his
excellent book on 44 Die doppelseitigen hamatogenen Nierenerkrankungen ” ; obvious
preventive therapeutic measures were suggested in that work.

Mr. R. H. PARAMORE asked whether the changes in the kidneys and liver which
led to uraemia were always due to a toxin : he was of the opinion that some toxemias

1 F. R. Fraser, .T. P. Ross, and N. R. Dreyer, “The Reaction of the Blood in Relation to
Dyspnoea,” Quart. Journ. Med., 1922, xv, p. 195.

- F. Parkes Weber and H. Schmidt, International Clinies, 1917, ser. 27, iii, p. 151 (case I>.

•** F. Parkes Weber and H. Schmidt, ibid., 1910, ser. 26, i, p. 89.

Section of Urology

ending in acute uraemia were caused by pressure—notably that occasionally occurring
in pregnant and parturient women and spoken of as eclampsia. In 1909, Dr. Parkes
Weber described a case of anuria with necrosis of the convoluted tubules occurring
in a man of 69 who died from carcinoma of the prostate.' The case was significant;
he (Mr. Paramore) believed the explanation was to be found in mechanical aberrations
induced by the disease. He asked whether the lesions of the renal convoluted tubules,
caused by poisons (taken by the mouth) affected these tubules uniformly; and pointed
out that in eclampsia, the cortical necrosis was more or less limited to the outer
two-thirds of the cortex.* If the necrosis were due to a toxin, he thought the tubules
would be uniformly affected: the fact that the parts nearest the medulla escaped indi¬
cated that the lesion was the result not of a toxin but of another cause. He agreed with
those who said that not only the kidneys but the liver also were affected in patients
exhibiting ureemia. The question was : What caused the lesions ? Considerable stress
had been laid on gastro-intestinal disturbances preceding the visceral changes associated
with uraemia. Whilst he readily agreed that this was so in chronic forms of the disease,
he was unable to allow that an acute uraemic toxaemia was caused in this way. 8 The
Dublin School of Obstetricians attributed eclampsia to poisons arising in the intestinal
tract; but this he thought untenable in view of the relatively short period of gestation.
Prostatic disease threw considerable light on the matter. The vomiting of altered blood
by patients during the first day or two after prostatectomy, noted in a case of his own
in which it was associated with great restlessness, and also referred to recently by
Sir John Thomson-Walker (President of the Section) at the Harveian Society/ indicated
that the liver circulation was disturbed. In the absence of gastric and other intestinal
ulcerations, and rupture of (esophageal veins, the vomiting of altered blood could only
be due to the bursting of gastric capillaries, which a clamping of the liver capillaries—
determined by the movements, the restlessness, the cries and the strains of the patient—
explained. Mention had been made of haemorrhagic diarrhoea occurring wdth an
epididymitis sometime after prostatectomy (and haemorrhagic intestinal extravasations
were not uncommon in eclampsia): that also must be attributed to hepatic circulatory
difficulties. Such changes were to be imputed to the manner of living of the patient
during his disease —to his movements, &c. That the kidneys were affected in the
same way by the same cause, he thought was plain. Recognizing in his own case that
the haemorrhagic vomiting was due to the increased intra-abdominal pressure determined
by the condition of the patient (a well-built rather stout and strong man), and that this
pressure was less in the lateral than in the supine position, and much diminished by
quieting the patient; he (Mr. Paramore) turned his patient on to the left side and
induced sleep, with the happiest of results. His surprise was complete and his
interest great when he found the President of this Section in his recent paper, 1 * * 4 5 already
mentioned, also advised that stout patients should be made to lie on their sides.
It was interesting to notice that the Dublin school of obstetricians insisted on the
lateral position in the treatment of eclampsia. They thought that this prevented
the patient drowning from the accumulation of mucus: but the more subtle change
in the pressure conditions to which he had alluded had not yet been considered.
The suppression of urine occurring after the rapid emptying of a urinary bladder
greatly distended (as in prostatic disease) supported his view that inactivity of the
kidneys, and so ureemia, were at times occasioned by physical causes. He cited the
opinion that in the pre-eclamptie state, Ctesarean section was occasionally followed
by fits; and that when this operation was done for eclampsia itself, the patient
occasionally was apparently made worse/' A more remarkable case w r as that published

1 Lancet , 1909, i, p. 601.

- Jardine and Kennedy, Lancet. 1920, ii, p. 120.

This wants defining—but for the moment cun stand. Perhaps we are on the track here of
acute yellow atrophy.

4 As reported in the Lancet of November 25, 1922, p. 1121.

Lancet , November 25, 1922, p. 1121.

From Dublin (private communication).

Mh-U 2

Langdon Brown: The Factors in Uraemia

in the Bulletin of the Paris Obstetrical and Gynaecological Society, in 1920, 1 of a
rachitic primigravida operated on at term. She was 24 years old, and was first
seen when seven months pregnant—Caesarean section at full time being advised.
From that time until term, the urine was examined twice every fortnight, no albumin
being discovered. On the morning of the operation (done at 10 a.m.), the urine
contained no albumin and no toxsemic symptom was present. At 4 p.m. the same
day, an eclamptic fit occurred followed by coma, and the catheterized urine was
found to be slightly albuminous. Two further attacks occurred, and then recovery.
He (Mr. Paramore) thought this case and the suppression of urine following the rapid
emptying of the greatly distended urinary bladder in prostatic disease were in line;
and that just as a mechanical factor explained the one, so it also explained the other.
What were the lesions found in the kidneys in these patients who died as a result of
suppression of urine ? Closer attention to such details was urgently called for, and
it was necessary to break away from the tradition that ail visceral diseases were due to
toxic agencies. Man was very largely a mechanical being, and if the mechanism went
wrong some chemical interaction or other was bound to get out of order.

• Bull, de la Sor. tVObst. ct rff- (rut . <lc Paris , 1920. xix, p. 444.

Section of TltrolOGp.

President—Sir John Thomson-Walker, F.R.C.S.

Case of Cyst of Prostate.

By Sir John Thomson-Walker, F.R.C.S.

J. N., MALE, aged 43, examined February 9, 1920. For four weeks had
complained of a poor stream and straining to pass water and frequent
micturition. Three days before I saw him a catheter was passed. This was
repeated twice daily, and from 14 to 30 oz. of residual urine removed. Apart
from use of catheter there was frequent desire, but very little urine was passed.
He was a strong healthy man, and there were no senile changes or signs of
nervous disease. The prostate, as felt from the rectum, was elastic and
movable, and very slightly larger than normal.

On cystoscopy there was a rounded bulging on the left of the internal
meatus, the outline of which was otherwise normal. The bladder was slightly
trabeculated, and the ureteric orifices normal. On opening the bladder a
large soft cyst the size of a walnut was found arising from the prostate at the
anterior and left edge of the internal meatus. The prostate was not enlarged.
I shelled it out with some difficulty, and it carried the cyst with it.

Recovery was uneventful, and there was no residual urine.

The specimen shows a prostate, little if at all enlarged, and on the upper
surface there is a thin-walled cyst the size of a walnut.

Case of Myosarcoma of Epididymis.

By Sir John Thomson-Walker, F.R.C.S.

M. M., MALE, aged 32, examined June, 1922. Patient noticed a lump
attached to the testicle about twelve months ago. This had gradually
increased in size, especially during the week previous to examination, but
there had not been any pain. There had been no injury, and the patient
denied venereal disease. In the globus major of the right epididymis there
was a very hard round nodule, the size of a marble. The surface was smooth,
and was not adherent to secondary structures. The testicle, remaining portion
of epididymis and vas deferens were normal, and nothing abnormal was found
elsewhere in the genital organs. The diagnosis lay between an unusual form
of tuberculous epididymis and growth.

Epididymectomy was performed, and on section the nodule was found to
be a myosarcoma.

Fifteen months later there was no recurrence. He was lost sight of after
that time.

My—U 1

[January 25, 1923

32 Thomson-Walker and Barrington : MalaJcoplakia

Case of Aberrant Prostatic Nodule.

By Sir John Thomson-Walker, F.RC.S.

C. A., MALE, aged 61, examined July, 1922. Complained of an inflamed
pile, and on examination of the rectum a greatly enlarged prostate was dis¬
covered. He had never had any difficulty in or urgency of micturition. There
was slight increase in the frequency of micturition to six or seven times during
the day and once during the night, and the stream was rather weak and finished
off slowly. He was a thin, very active man, who had lived in India and China
for twenty-two years, and had returned to England eighteen years ago. The
abdomen was flat. There was a prolapsed thrombosed pile. There was no
distension of the bladder or enlarged groin glands. The urine was normal.
The prostate was small, elastic and movable. Above and to the right of the
prostate was a large firm elastic mass, which was rounded somewhat, and
nodular. On one part of the surface a cyst could be felt. The mass was
separated from the prostate by a groove and occupied the position of a greatly
enlarged seminal vesicle. There was no shadow shown by the X-rays.

On August 16, 1922, I opened the bladder suprapubically. There was some
bulging at the right base behind the trigone. On palpation, the greater part of
the mass was in this situation, but it extended over to the left as far as the
level of the left ureteric orifice. The trigone and ureteric orifices were normal,
and there was no change at the internal meatus. A median incision was made
from just behind the posterior lip of the internal meatus through the trigone
muscle and base of the bladder. A rounded, elastic, nodular mass was exposed,
and was enucleated by blunt dissection. It was surrounded by a smooth
capsule which was slightly adherent, anteriorly and laterally, but there was no
pedicle, and no connexion could be traced with the prostate or seminal
vesicles. The latter were not seen during the dissection. The resulting cavity
was drained, and the floor of the bladder united.

The specimen was a firm, elastic, round body, the size of a tangerine orange.
The surface was smooth, and at parts shows bosses due to small cysts.

Section showed firm, opaque white tissue, in which were embedded numerous
cysts filled with milky fluid. Microscopic section showed a fibro-muscular
stroma with glandular alveoli similar to the gland tissue of the prostate. The
alveoli were dilated with cysts of varying size, and the whole structure was
that of senile enlargement of the prostate. There was no sign of malignant
changes at any part.

Post-operative examination confirmed the observation that the prostate
was normal in size and consistency.

Case of Malakoplakia.

By Sir John Thomson-Walker, F.R.C.S., and
F. J. F. Barrington, M.S.

Mrs. L., aged 43, examined October, 1914. Four months previously
noticed pain at the end of micturition which gradually increased. Terminal
haematuria appeared about the same time and increased until the haemorrhage
was severe for about fourteen days, when she was admitted to hospital.
The pain and haemorrhage were increased by movement. The frequency of
micturition was increased to about six times during the day and twice at

Section of Urology

night, and some days the interval was reduced to a few minutes. She had
resided and travelled abroad. Two years ago, and again four years ago, she
had visited Burma, and since 1897 had lived in India, with intervals of some
months in England, and had passed through Ceylon and Egypt.

There was no family history of tubercle. Ten years ago she had pleurisy,
and as a child had malaria and pleurisy.

On cystoscopy the bladder held 12 oz. without pain, and there was no
difficulty in getting a clear medium. The whole of the mucous membrane of
the bladder, with the exception of the trigone and a small area behind this,
was strewn with yellow plaques, which varied in size from a very small point
to an area the size of a threepenny piece. Viewed from a distance the colour
was yellowish pink, but on closer inspection it was pale yellow. On the
posterior and lateral walls of the bladder the plaques were discrete and dis¬
tribution was very irregular. Behind and to the outside of the left ureteric
orifice there were a number of large plaques, and to the right of the trigone
there was an area closely covered with plaques which had become small
nodules. A plaque was flat or nearly so on the surface, it had a rolled-over
edge and stood up sharply from the mucous membrane. The central part was
frequently a little depressed, somewhat like the nodules of molluscum con-
tagiosum. They were rounded or oval. Closely examined, they had the ap¬
pearance of a caseous nodule covered with a thin layer of epithelium*
Occasionally the base was a little contracted so that the edge rolled over.
Around the edge of the plaque there was a halo of moderate inflammation in a
few plaques, but in most of the plaques there was no sign of reaction in the
mucous membrane around, and there was no ulceration. The mucous mem¬
brane apart from the plaques was healthy. The ureteric orifices were normal
with a slight reddening of the lips.

On November 2, 1915, the bladder was opened suprapubically. The area at
the apex of the bladder was found thickly studded with plaques, and they
extended down the posterior wall. The plaques could be distinguished with
the finger as raised areas in the mucous membrane. In parts they felt leathery
and the isolated plaques were hard to the touch and felt like a plaque of
xanthelasma, or a hard chancre on the foreskin. A number of the plaques
were excised and the remaining areas treated with solid nitrate of silver. The
plaque was entirely confined to the mucous membrane and did not penetrate,
and was not adherent to, the muscular coat.

Histological Examination .—A section of plaque stained with haBmatoxylin
and eosin shows that it consists of a mass of cells situated immediately deep
to the position of the epithelium. The epithelium lies directly on the cell
mass at the sides but over the central part it is absent. On the deep surface
a layer of the submucous areolar tissue separates the cell mass from the
muscular coat of the bladder. Interstitial tissue in the cell mass is very
scanty and is represented by a few blood-vessels and fine strands of areolar
tissue which have a general direction vertical to the surface. The majority of
the cells of the mass are large with a finely spongy eosin-staining cytoplasm
and a small deeply-staining eccentrically situated nucleus. In the deeper parts
of the plaque these cells are polygonal from mutual pressure, but near the sur¬
face, where they are arranged more loosely, they tend to be rounded and
slightly larger. Michaelis-Gutmann bodies are present in many of the large
cells, sometimes singly and sometimes as many as five in one cell. These
bodies are more or less round, and vary in size up to about twice that of the
cell's nucleus: they stain much more faintly with hsematoxylin than do the

Ball: Necrosis of Kidney

nuclei, some appear homogeneous, while others have a definitely concentric
structure. At the edges and base of the plaque there are numerous small
round cells; most of these are mononuclear, and at the base of the plaque
they show a marked tendency to be arranged in closely packed foci. A
few scattered large cells of the same kind as those forming the plaque are pre¬
sent in the areolar tissue deep to its base. Some of these large cells contain
Michaelis-Gutmann bodies. A few Michaelis-Gutmann bodies of unusually
large size are found in the zone, outside the cells. No bacteria are present in
the section.

Necrosis of Kidney following Ligature of Abnormal Renal

Vessels.

By W. Girling Ball, F.R.C.S.

This specimen was obtained from a woman, aged 35, who was admitted to
St. Bartholomew’s Hospital on February 25, 1922. It shows the kidneys,
pelves and ureters, together with the blood-vessels attached thereto. The main
point of interest is the necrosis of the lower pole of the left kidney which
followed the ligature of an abnormal renal artery and vein, which had caused
kinking of the ureter and a consequent large hydronephrosis. The line of
suture, after excision of part of the wall of the sac, can be seen and it demon¬
strates the straightening of the ureter which followed this procedure. The
ligatured vessel has been dissected out, and is seen to come off as a separate
vessel directly from the aorta. An abnormal artery is present on the opposite
side and shows a kinking of the ureter of that kidney. There is another
large vessel below the main artery which is possibly the remnant of a previously
ligatured vessel.

The microscope slide shows the necrosis of the renal tissue at the lower
pole of the kidney.

The history of the case was that of renal colic associated with a swelling on
the left side of the abdomen and polyuria extending over a period of fourteen
months. The patient related that she had had a similar condition on the right
side, giving symptoms for twenty-one years ; for this she was operated on and
had an abnormal renal artery tied two years previously. This is interesting
seeing that the specimen still demonstrates the presence of such a vessel; she
had not had any symptoms relating to the right side since the operation. The
diagnosis of kinking of the left ureter was made by pyelography, the X-rays
showing a typical picture.

She was operated upon on March 13, 1922. A considerable hydronephrosis
was found, resulting from the kinking of the ureter at a very acute angle over
two vessels entering the lower pole of the kidney. These vessels were large in
size, but the main renal vessels appeared to be normal. The accessory vessels
were ligatured and divided. A Y-shaped portion of the posterior wall of the
hydronephrosis was excised and sewn up again with a double layer of sutures ;
in this way the kink in the ureter was straightened. After this the kidney at
first appeared engorged at its lower pole, but subsequently its normal colour
returned. The wound was drained.

On the day following the operation the patient’s abdomen became distended,
but relief was obtained by the use of enemata; the distension, however, in¬
creased despite the passage of flatus. There was no leakage of urine from the
wound or evidence of perirenal infection. She died suddenly on the third day.

Section of Urology

Post-mortem .—There was oedema and a certain degree of suppuration
about the lower pole of the kidney and the upper end of the ureter. In front
of the pole of the kidney was a small suppurating focus, attached to and infect¬
ing the peritoneum to the inner side of the colon. The peritoneum was intact.
Here there was a small focus of suppurative peritonitis, with a spreading
general peritonitis and great distention of the small intestine. The sutured
pelvis did not show any evidence of leakage.

Specimen showing Transitional-celled Growth of the Kidney.

By W. Girling Ball, F.R.C.S.

The specimen shows a kidney, the upper pole of which is occupied by an
oval tumour in. in diameter. The tumour is surrounded by a capsule
composed mainly of a condensation of the surrounding kidney. It is of
fairly uniform appearance, semi-translucent, and of a pale yellow colour;
the clear-cut surface presents a somewhat granular structure. Projecting
into the pelvis of the kidney and extending down the ureter for about an
inch is an extension of the growth of similar appearance, except that there is
no surrounding capsule, and the tissue is superficially somewhat necrotic. This
extension of the main mass has produced some blockage of the ureteric orifice,
which has resulted in the production of a condition of hydronephrosis in the
portion of kidney free from the tumour. The renal tissue here is almost com¬
pletely absent.

Microscopic Appearances .—The microscopic section of the growth shows
that the tumour is composed of transitional cells of the type met with in the
lining of the pelvis, ureter and bladder. The cells are arranged as an epithelial
membrane, but much thicker than normal, which is thrown into a large number
of folds upon a fine supporting stroma containing blood-vessels. This is
the fundamental arrangement, but here and there the structure is more compli¬
cated and cell proliferation is more active and of a less regular type. The
section does not show actual invasion of the kidney by this growth, which
originated in the pelvis. It is a transitional-celled papilloma, which exhibits
some appearance of malignancy.

The kidney was removed from a female patient, aged 38, in September,
1922, who had had almost persistent haematuria for a period of ten months.
This was associated with pain and swelling in the left loin. A curious
feature in the bleeding was the fact that it only occurred in the morning or
after lying down, disappearing completely during the day. The pain was
no doubt caused by the hydronephrosis, and the intermittent character of the
hasmaturia by the temporary blockage of the ureter by the tongue of growth.
There was no evidence of metastasis. The patient made an excellent recovery
and has remained well up to the present.

Absent Right Kidney; Deformity of Left Ureter.

By W. Girling Ball, F.R.C.S.

The cystoscope pictures illustrate the following case : A boy, aged 9, was
suddenly taken ill on August 8, 1922, with abdominal pain and vomiting. His
doctor discovered a sausage-shaped swelling on the left side of the abdomen
extending from under the ribs to the level of the brim of the pelvis ; it could be

36 Ball: Absent Right Kidney; Sutcliffe: Two Large Calculi

felt in the pelvis in front of the rectum. There were no urinary symptoms.
This swelling proved on exploration to be an enormously distended left ureter,
which was opened extraperitoneally and found to be connected with a distinctly
hydronephrotic kidney; the cause of the dilatation could not be discovered.
The hole in the ureter was sewn up.

The boy remained well for a fortnight, when the ureter again filled up, but
on this occasion it emptied itself in the bladder on the application of hot
fomentations to the abdomen. A week or so later it again filled and this time
discharged itself through the incision in the loin. Occasionally after this the
boy passed his water by the bladder and then the fistula closed, but when
there was leakage through the fistulous track he did not pass any water from
the bladder at all. It thus seemed probable that there was no right kidney
present. Efforts were then made to prove this, and also to find out the cause
of the obstruction to the left side.

Cystoscopic Appearance .—(l) Marked twisting of the ureteric orifice on the
left side, and the absence of an orifice on the right. There was no obvious prolapse
of the left orifice. (2) Repeated X-ray examination failed to demonstrate the
presence of a left ureteric calculus or the presence of either kidney. (3) The
injection of dyes failed to demonstrate the presence of a right ureteric orifice.
(4) As the boy now had a fistula from what appeared to be his only kidney,
something had to be done.

Operation : The peritoneal cavity was first opened. There was no evidence
of a right kidney, rudiment of such, or of a ureter. The left kidney was very
large and cystic. The peritoneum was closed and the incision extended down¬
wards to the suprapubic region. The bladder was opened and the ureteric
orifice examined. There was no prolapse. The bladder was then drawn out of
the pelvis and the peritoneum pushed up, and the distended ureter traced down
to the point of its insertion into the bladder; the last inch, of the ureter was
normal in calibre, and from that point upwards the dilatation commenced
without obvious cause. The normal portion of the ureter was divided between
ligatures. The upper portion was freed and divided above the point of
narrowing and implanted into the bladder at a point higher up on its wall.
The bladder was drained suprapubically. The wound rapidly healed and the
boy has remained well since.

Appearance seen in November, two months after the operation: The
orifice stands open, but contracts down considerably as if at the termination
of a peristaltic wave from the ureter; it does not completely close. The boy
remains quite well.

Two Large Calculi removed from the Perinaeum of a Male,
aged 62 , in Margate Cottage Hospital.

By W. G. Sutcliffe, F.R.C.S.

(Shown by Cyril Nitch, M.S.)

The patient had suffered from a perineal urinary fistula complicated by
frequent perineal abscesses following an operation forty-two years ago for
a ruptured urethra in University College Hospital. During this period he had
never consulted a doctor. Some urine was passed by way of the urethra, but
the greater part escaped through the perineal fistula. When seen by Mr. Sutcliffe
in April, 1922, two hard, rounded masses were felt occupying the region between

Section of TJrology

the anus and the peno-scrotal angle. A sound passed by way of the urethra
grated against a stone. At the operation, by Mr. Sutcliffe, the stones were
found to occupy a large sac which communicated with the urethra. The
large stone weighed 13i oz. and the small one li oz. An attempt was made
to close the sac by suture, but the fistula soon re-formed. Both stones
were found to consist of calcium phosphate.

Specimens of New Growth of the Pelvis and Kidney.

By J. McAlpine, M.B.

(I) Simple Papilloma op the Renal Pelvis.

The specimen was removed from a man, aged 45, who presented himself
as the result of a copious haematuria of sudden onset. This was accompanied
by clot colic. In other respects the history of the case was painless. It is
worthy of notice that the organ was palpable, and was diagnosed as being
increased in size. I find from a glance at the literature, that it is uncommon
for papillomata of the kidney to give rise to an increase in size of the organ,
unless this increase be dependent on the development of a hydronephrosis as
the result of blocking of the ureter by the growth ; there is no hydronephrosis
in my specimen. I should say that the papilloma is one of fairly considerable
size, though as I have not myself seen a great many of these specimens, I am
unable to compare it with others. It presents all the characteristics of a
papilloma as seen either in the bladder or elsewhere. There are numerous
secondary splashes on those parts of the pelvis which are not primarily
affected. There was one point of interest in the post-operative history; the
patient suffered from clot colic shortly after coming round from the
anaesthetic, and for a period of thirty-six hours the urine was stained with
blood. At the operation I had removed just as much of the ureter as I
could conveniently by the loin incision, the danger resulting from secondary
implantation in the ureter having temporarily escaped me. On the bleeding
occurring I did not, however, submit the patient forthwith to a complete
ureterectomy, and as events have turned out, it is probable that the colic
and haemorrhage were due to blood which had been squeezed out of the
papilloma by the manipulations at operation. It is now six years since I
removed this kidney and I have kept the patient under observation at frequent
intervals, and have cystoscoped his bladder periodically ; there is no suspicion
of recurrence. The possibility, even probability, of secondary implantation
in the ureter should, I think, make one resort to nephro-ureterectomy rather
than nephrectomy in all such cases.

(II) Malignant Papilloma op the Renal Pelvis.

This is perhaps more interesting as a specimen. It was removed from a
male patient, aged 56, whose only symptom was haematuria. The diagnosis
of the site of origin of haematuria was complicated by the fact that he also
presented a medium prostatic bar, which tended to bleed on the introduction
of the cystoscope. The haemorrhage was, however, traced to the left ureteral
orifice and the opposite kidney being diagnosed as of adequate capacity, the
present specimen was obtained. This organ was not palpable in the loin,
and the patient had never suffered any pain or discomfort attributable to the
gland.

38 McAlpine: Growth of Pelvis and Kidney; Ward: Calculus

The specimen is that of a kidney of normal size, and there is no lesion
of the capsule or parenchyma apart from the tumours calling for comment.
In the pelvis may be seen a number of small sessile, papillomatous tumours
none of which is larger than a millet seed, springing from the mucosa. One
of these is to be observed occupying a position high up in a renal calyx, and
in close proximity to the two tumours of the parenchyma.

One of these two latter tumours is about i in. in diameter, and occupies
the mid-zone of the kidney, being situated more in the medulla than in the
cortex; it is soft and encephaloid in consistency, maroon-coloured, and gives
the impression of being partially encapsuled.

The second parenchymal tumour has a different appearance, it is scirrhous
in type, white and glistening, and is evidently infiltrating the kidney substance.
I submitted this specimen to Professor Dean, who was then Professor of
Pathology at the Manchester University, and he cut for me the three slides
which I have exhibited this evening. He is of the opinion that the growth
in the pelvis of the kidney is primary and that each of the two growths in the
parenchyma is secondary, one having taken on the encephaloid type and the
other the scirrhous type.

This nephrectomy was performed about fifteen months ago and I was
called to see the patient within the last month. I found he had done well
until within a fortnight of my seeing him, when he began to show signs of
cachexia. On examination I found a considerable mass occupying the left
upper quadrant of his abdomen, which was evidently a neoplasm secondary
to the kidney lesion.

(Ill) Massive Calculus Formation in the Kidney.

The last specimen is only interesting as a specimen, but it illustrates
also the silence of patients suffering from calculus of this kind. *.|The
patient was a man, aged 29, who had never suffered from any symptoms
indicative of stone formation in his kidney, with the exception of an occasional
slight ache in the loin. The symptom which brought him to me for treatment
was again hasmaturia; the absence of pain with such enormous masses of
stone in the kidney is indeed remarkable.

A Large Renal Calculus.

Shown by R. Ogier Ward, F.R.C.S.

A LARGE renal calculus, composed throughout of ammonium magnesium
phosphate with a little calcium oxalate and on its surface some calcium car¬
bonate : weight, 555 grm. (1 lb. 2£ oz.). Also a ureteric calculus of the same
composition : weight, 2’8 grm. These, with the kidney and ureter, also shown,
were removed from a man aged 58. For twenty-three years the patient's urine
had been intermittently blood-stained; sometimes there had been sufficient
hsBmorrhage to cause retention of urine in the bladder from clot formation. He
had never had any renal or vesical pain. For five years recently his urine had
smelt offensively. For two weeks only he had had marked frequency fof
micturition, fever and some rigors.

On examination the left kidney could be felt to be greatly enlarged and un¬
usually firm. The urine was heavily infected with a coliform bacillus, and
with cocci. Cystoscopy showed acute cystitis, a swollen left ureteric orifice,
from which there were frequent purulent effluxes. The prostate was enlarged.

Section of Urology

X-rays showed the ureteric calculus and a dense shadow in the left renal
region. Nephrectomy was performed in the usual manner, 8 in. of greatly
thickened ureter and the ureteric calculus being also removed.

The renal calculus occupied the greatly dilated and thickened renal pelvis,
much of the kidney remained in a fairly healthy condition, but showed on
microscopical examination a condition of chronic interstitial nephritis.

Two Cases of Glandular Epispadias.

By J. Swift Joly, F.R.C.S.

GLANDULAR or balanitic epispadias is the most uncommon form of this
condition. In 1904 Katzenstein 1 could only collect five cases from the litera¬
ture, and I do not know of any others since reported. As this condition is so
rare, I thought it might be of interest if I described.} two cases which have
recently come under my care.

Case I. —Well-developed boy, aged 12. At first sight the external genitalia
appeared normal, except that the penis was slightly stunted. The prepuce.was
long, and in its normal position entirely hid the defect. When it was fully

Fig. 1.—Case I.

retracted, it was seen that the urethra opened on the dorsal surface of the penis,
immediately behind the corona glandis. A deep groove extended from this
point to the usual position of the external meatus. It involved the whole
thickness of the corona, but in front of this point it only extended about half¬
way through the glans (fig. l). Its greatest depth was 6 mm. The groove was

1 Quoted by Nove-Jusserand and Gayet, “ Encyclopedic franyaise d’Urologie,” v, p. 900.

Joly: Two Cases of Glandular Epispadias

lined with mucous membrane, which was of a much deeper pink than the
epithelial covering of the glans. There was no stricture. A No. 12 F gum-
elastic bougie was passed, and the urethra palpated when it was in place. The
corpora cavernosa were separated from each other, and the urethra could be felt
with equal ease from the dorsal and from the ventral aspects of the penis.
On perineal and rectal examination the course of the urethra appeared to
be normal. The testicles were well descended, but rather small considering
the age of the boy. The pelvic girdle appeared to be normal, but no
X-ray examination was made. As the boy was in excellent health, and
suffered no inconvenience from this defect, no operation was advised.

Case II .—Well developed boy, aged 7. At birth the penis w^as attached
to the abdominal wall by a thin web involving only the skin. This was

Fig. 2.—Case II.

divided when he was 11 months old. Four years later he began to
suffer from diurnal incontinence. This steadily got worse, and when I saw
him the urine was constantly dribbling away. On examination, the penis
was found to be small and stunted, the prepuce long and voluminous. A
vertical oval scar, about li by i cm. was seen immediately in front of the
pubis, and another of almost equal size was visible on the dorsal aspect of
the prepuce. When the prepuce was fully retracted, a rather stenosed
urethral opening was seen in the middle line, immediately behind the
corona. From this a very deep groove extended forwards. It involved
almost the whole thickness of the glans penis (fig. 2). Its greatest depth was
1 cm. The whole groove was lined with pink mucous membrane, which formed

Section of Urology

a distinct ridge on each lateral wall. These were well marked in the posterior
half of the groove, but when traced forwards, gradually diminished in size,
and disappeared entirely about 3 or 4 mm. from the tip of the penis. This
patient had a very tight stricture of the penile urethra, about 1 cm. behind
the abnormal orifice, which was fully dilated under general anaesthesia. The
penile portion of the urethra was dorsal to the corpora cavernosa, which were
united to each other. The deep urethra was normal in position. The testicles
were only partially descended, and lay a short distance below the corresponding
external rings. There was a small hernia on the right side. The pelvic girdle
was normal. The incontinence was due to the stricture, and disappeared as
soon as it was dilated.

Multiple Cystic Formation in Lower Pole of Kidney.

By R. H. Jocelyn Swan, O.B.E., M.S.

W. R. C., MALE, aged 36, seen in 1916, gave a history of an attack of acute
pain in loin four years previously, but could not remember on which side it
occurred. Patient awoke one night three weeks before with urgent desire
to micturate and found urine deeply stained with blood. Had to get up
frequently during night and urine remained blood-stained for two days.
Similar attacks have occurred on two subsequent occasions, each lasting
two to three days. During the attacks of haemorrhage there is frequent
micturition and the urine varies considerably in colour, sometimes being clear
on one occasion and blood-stained the next. No pain on micturition and no
pain nor aching in loins.

On examination: Strong, healthy looking man. No pain of any sort.
Urine deeply stained with red blood, acid, specific gravity 1016. No casts
and no pus found. Left kidney distinctly palpable and enlarged. Not tender
on pressure. Right kidney not felt. Testes normal. Per rectum : Prostate
and vesicles normal; ureters not felt. Cystoscopy in 12 oz. distension.
Bladder normal. Blood-stained urine in feeble but frequent efflux from left
orifice, which was normal in appearance. Clear urine from right orifice.
Catheter passed into right ureter and urine collected found to contain 2’2 per
cent. urea. Skiagraph: No shadow of calculus.

Operation: Left kidney exposed and lower pole found to be occupied by
numerous cystic cavities containing blood-stained fluid under tension. Area
was firm and with suspicion of growth; kidney was removed.

Patient has been seen recently and is in perfect health. Urine is clear;
free from albumin. Specific gravity 1020.

Pyonephrosis due to the Kinking of the Ureter by Aberrant

Renal Vessels.

By R. H. Jocelyn Swan, O.B.E., M.S.

A. D., FEMALE, aged 47. Had had attacks of dull, aching pain in left loin
for twenty years, with occasional severe attacks of acute pain accompanied by
vomiting and collapse. Pain localized in loin with increased desire to micturate
during severe attacks. During the last three months the pain had been much
more severe and more frequent. Patient states that after an attack of acute

42 Swan: Prostate removed by Prostatectomy

pain the urine is thick and deposits a white sediment. Hfflmaturia has not
been seen.

On examination: A rounded tumour was easily palpable in the left loin,
presenting the features of a renal swelling. Eight kidney not palpable.
Urine acid, specific gravity 1012, albumin present. Deposit contained pus
and a few blood cells. Sugar absent. Cystoscopy: Bladder normal. Ureteric
orifices normal, efflux from left orifice seen to be purulent. Chromo-cystoscopy:
Blue coloration of the efflux from right orifice five minutes after an intra¬
venous injection of indigo-carmine. No coloration from left orifice after
fifteen minutes. Blood urea : 23 mg. in 100 c.c. of blood. Urea concentration:
1*8 per cent, in 2£ oz in first hour, 3*4 per cent, in 1 \ oz. in second hour;
2*8 per cent, in 1^ oz. in third hour.

Operation: Kidney found with a very dilated pelvis together with renal
dilatation from the acute flexion of the ureter at the junction with the pelvis
over a tense band containing large vessels running to the lower pole of the
kidney. The main renal vessels entered the kidney at the upper part.
Nephrectomy was followed by uninterrupted recovery.

Prostate removed by Prostatectomy ; Weight, 12 oz., or

340 grm.

By K. EL Jocelyn Swan, O.B.E., M.S.

E. C., AGED 81. Had had trouble with frequent micturition for many
years and seven years ago was advised to pass a catheter night and morning.
For the last two years he has been entirely dependent upon the catheter, but has
found difficulty in passing it, bleeding and pain often being caused. Catheter
passed about six times a day. No backache, no increased thirst, and takes
food well.

On examination : Good colour ; does not look his age. Pulse 70, arteries
thickened; blood-pressure 160 mm. Tongue slightly coated, moist. Urine:
neutral, specific gravity 1010, small deposit of pus, without odour; albumin
present. Bladder not distended. Neither kidney felt. Catheter had been
passed half an hour before patient was seen. Per rectum : Very large soft,
elastic prostate felt. Was under observation for several days during which
the daily amount of urine averaged 70 oz. with daily excretion of 370 grains
(average). Urea concentration : Before test, urea 1*7 per cent.: after one
hour, urea 2*1 per cent, in 3 oz.; after two hours, urea 2*2 per cent, in 6 oz.

Operation: Suprapubic prostatectomy, September 18, 1922. Very large
intravesical projection and considerable difficulty in enucleation owing to the
size of gland. Each half removed separately. Condition good at end of
operation.

September 19 : Was cyanosed; pulse 120 and respirations 40; only 11 oz.
drained in twenty-four hours.

September 20: Eapid collapse, and died at 8 a.m. Only 2 oz. drained
in previous twelve hours.

Section of Urology

Specimen showing Interior of the Bladder Six Months after
Extensive Resection for Carcinoma, with Transplantation
of the Right Ureter.

Shown by John Everidge, O.B.E., F.R.C.S.

From a patient, aged 43, from whom in April, 1922, I resected practically
the whole of the right half of the bladder for carcinoma. The right ureter lay
in the centre of the growth and was resected and implanted into the wound.
At the completion of the operation the lumen of the reconstructed bladder was
cylindrical—about the size of the middle finger—being built up around a
medium sized drainage tube. The suprapubic wound healed in three weeks,
and two months later urine could be held for four or five hours.

In November, 1922, hearing that a friend had died of cancer, he shot out
his brains, from the fear that he might be afflicted by the same disease.

The chief interest in the specimen lies in the healthy and uncontracted
new orifice of the implanted ureter, as well as in the striking absence of scar
tissue.

Specimen of Diverticulum of the Bladder.

Shown by John Everidge, O.B.E., F.R.C.S.

This specimen shows a sac as large as the bladder, and communicating by
a narrow stoma with the main cavity. It springs from the right lateral wall
of the bladder above and behind the right ureteric orifice. Both ureters open
into the main bladder, and neither presents any obvious dilatation. The
kidneys also appear normal to the naked eye, no hydronephrotic changes having
occurred. Microscopically the kidneys show marked engorgement of the
vessels, and early fibrosis around the glomeruli. The wall of the bladder is
distinctly trabeculated, but there are no other diverticula. The wall of the
sac presents muscle fibres.

Clinical History .—From a male, aged 50, admitted to a medical ward on
account of uraemia. The patient gave a history of stricture, but no hindrance
was found to the passage of a catheter, and no tangible source of urinary
obstruction could be found. No lesion of the central nervous system was
discovered. Death from uraemia took place four days after admission to
hospital.

Case of Ectopia Testis.

By A. Clifford Morson, O.B.E., F.R.C.S.

AMONGST numerous examples of misplaced organs which appear from time
to time in medical journals, there are, perhaps, none more interesting than
those relating to the sexual apparatus. The development of those structures
which determine sex is dependent upon factors of which little is known, and
therefore the raison d’etre of their appearance in positions sufficiently unusual
as to cause their owners considerable inconvenience is a matter of conjecture.

Morson: Ectopia Testis

A youth, whose abnormality had remained unknown to him for seventeen
years, presented himself in August, 1920, at my Out-Patient Department of the
Hampstead General Hospital with the complaint of aching in the right groin
when bicycling or running fast. On examination I noted that the lad was well
built, of good muscular development, and, for his age, had a plentiful growth
of pubic hair. The penis and left testicle were normal. The right side of the
scrotum was undeveloped, and the right testicle could be seen as a definite
swelling on the inner side of the thigh about 3 in. from the anal margin (see figure).
Pressure upon the gland produced the characteristic sensation associated with
the normal testicle, and its size was approximately the same as the left. There
did not appear to be any other anatomical peculiarities.

Having obtained consent to operate, I decided to replace the right testicle
in the scrotum. An incision was made over the right testicle, and the
the spermatic cord isolated as it emerged from under the free edge of the
external oblique aponeurosis. To pull the testicle out from beneath the skin
was a simple matter, there being no process of fibrous tissue anchoring it down.
A passage was next made into the right side of the scrotum with sinus forceps,
considerable stretching of the tissue being necessary in order to fashion a tube
large enough to admit the testicle into the scrotum. The misplaced organ
when exposed was anatomically perfect. When the operation had been com-

Section of TJrology

pleted the skin of the right side of the scrotum was tense, and entirely free
from rugae. Within seven days this half of the scrotum had acquired the
normal rugose appearance, and showed no evidence of lack of development.
The patient was discharged from hospital ten days after operation with no
outward manifestation of disability apart from the scar in the thigh.

Two and a half years have now elapsed since this operation, and the
position of the right testicle in the scrotum remains normal. However, the
development of this organ seems to have been arrested, for while the left
testicle is of adult size, the right is no larger than it was in August, 1920.
Sensation to pressure is also dulled, and I am of opinion that ultimately
complete atrophy will take place.

Serous Cyst of the Kidney.

By Kenneth M. Walker, F.R.C.S.

The patient was a woman, aged 65, admitted to the Royal Northern
Hospital, under my colleague, Dr. Malcolm Donaldson, for a large cystic
swelling the size of a coco-nut on the left side of the abdomen. The diagnosis
lay between an ovarian cyst and a cystic kidney, and I was asked to examine

her from the point of view of differential diagnosis. There were no symptoms
of any sort, and the patient suffered no disability from the presence of the
cyst. The vaginal examination showed that the cyst was entirely independent
of the uterus and its adnexae. In palpating the abdomen I thought I could
feel the left kidney lying above the level of the cyst, and was inclined to
believe that the cystic swelling was not renal. However, to clear up matters

Walker: Serovs Cyst of the Kidney

a pyelogram was made. Cystoscopy showed a normal bladder, with normal
effluxes from both orifices. On the left side the ureteric catheter became fixed
some 12 cm. up the ureter. The pyelogram was of great interest (see figure, p. 45).
It showed that the left kidney was low in position, its hilum being at the level of
the lower border of the second lumbar vertebra. The pelvis was distinctly dis¬
torted, forming a semilunar shaped cavity stretched over the upper border of the
large cyst, the edge of which could be plainly seen in the skiagram. The
result of this was to show that the cystic swelling was undoubtedly connected
with the left kidney. On lumbar exploration, Dr. Donaldson found a large
serous cyst bulging from the lower pole of the kidney, and a nephrectomy was
performed. Microscopic sections of the kidney showed some chronic interstitial
nephritis with areas of round cell infiltration.

The case owes its interest to the fact that single serous cysts of the kidney
are extremely rare, and that as far as I know a pyelogram of such a condition
has never before been made. Guinsbourg in his “ Contribution k l*6tude des
grand kystes du rein” (Dissert., Paris, 1903), was only able to collect up to
the time of his report thirty-nine cases of single serous cyst. Their aetiology
is still obsoure, some authors regarding them as retention cysts and others as
comparable to polycystic kidneys, but neither explanation is entirely satis¬
factory. In some cases the kidney itself is quite healthy, and conservative
operations have been performed, the first one by Tuffier in 1897. The
interesting features of the pyelogram are the manner in which the pelvis has
been stretched round the cyst and the clearness with which the outline of the
cyst appears in the photograph. Owing to the fact that the cyst burst during
removal it was impossible to collect any fluid for examination, but whatever
the composition of that fluid may have been, it was such as to cast an
extraordinarily good shadow.

Section of WrolOGP.

President—Sir John Thomson-Walker, F.R.C.S.

The Propriety of attempting to secure Primary Union after
Operations upon the Bladder and Prostate,

By A. Ralph Thompson, Ch.M., F.R.C.S.

The object of this paper is to raise a discussion upon the advisability of
suturing the bladder in certain cases of suprapubic cystotomy.

Without doubt, in the present state of our knowledge, no effort should be
made to close the bladder after operations performed for certain conditions,
particularly in those cases in which it is desirable to establish free drainage,
either for bladder or kidney conditions.

I have on record from my wards at Guy’s Hospital or from private practice
thirty-one cases in which the bladder and the abdominal wall were deliberately
sutured after suprapubic cystotomy. In a few cases a gauze drain was inserted
superficially; and in all such cases the gauze drain was not retained for more
than two days, and in some cases only for twenty-four hours, but in the larger
number of cases no superficial drainage was provided.

These cases of attempted primary union after operations upon the bladder
or prostate by the suprapubic route may be arranged under seven heads,
according to the nature of the condition which gave rise to the operation.
These heads are as follows : (I) Adenoma of prostate : (II) malignant disease
of prostate ; (III) adenoma of prostate accompanied by the presence of vesical
calculi; (IV) growth of the bladder; (V) vesical calculi; (VI) retrograde
catheterization; (VII) exploration of bladder (see Table, p. 48).

(I) Adenoma of the Prostate.—Fourteen Cases.

Suprapubic prostatectomy was performed in all these cases. The average
age of the patients was 64, varying downwards from 85 to 54. The average
stay in the hospital after operation was twenty-nine days.

[I have chosen ten cases of suprapubic cystotomy from my records in
which the bladder was not sewn up, but allowed to heal of itself. I find the
average stay after operation was in these cases forty-five days.]

Of these cases, fourteen in number, one male, aged 63, died of uraemia after
operation. I ought not to have closed the bladder, and in fact I cut the
stitches within six hours of the operation and placed a tube in the bladder.
The patient, however, died on the fourth day after operation. Three cases
had a leakage of urine through the wound for a very short time ; two of these
recovered perfectly, and in one the wound broke down slightly, necessitating
readmission to the hospital for ten days, during which time the patient got
quite well and is now in very good condition. When the term “ leakage ” is #
used it is meant only that the dressings were very slightly damp.

Je—U 1 [February 22, 1928.

48 Thompson: Operations upon the Bladder and Prostate

Table Showing Cases of Primary Union after Suprapubic Cystotomy.

(I) Simple Adenoma of Prostate.

Leakage No leakage Complications Death

fl) Adlam ... 58 (8) Bignell ... 64

(2) Coles ... 65 (9) Butcher ... 65 (28) Collins ... 63

(10) Cox ... 60

(11) Hill ... 70

(12) Howell ... 56

(18) Johns ... 54

(14) Lane ... 66

(16) Metcalf ... 85

(16) Nightingale 54 Bacilluria

(3) Wellings ... 71 (17) Rogers ... 64

Average age, 64 ; average stay in hospital after operation, twenty-nine days.

(II) Malignant Disease of Prostate.

(18) Lambert... 69

III) Simple Adenoma of Prostate -f Calculi.

(19) Cooper ... 65

(20) Jourd ... 60 (29) Sieveyer ... 68

(IV) Grou'ths of the Bladder.

(4) Duncan ... 43 (female) (21) Collins ... 48 (female) Slight (30) Burton ... 38 (female)

recurrence

(5) Phillips ... 19 (22) Jones ... 44 (female)

(6) Roper ... 63 (23) Monser ... 69

(24) Patmore... 37

(25) Ward ... 29 (31) Ritchie ...56

Average age, 44£ ; average stay in hospital after operation, twenty-five days.

(V) Vesical Calculi.

(26) Mylam ... 50

(VI) Retrograde Catheterisation.

(27) Elboume 30

(VII) Exploration.

(7) Collins

Average stay in hospital of ten non-selected cases (apart from fistula), wound left

open, 45J days.

(II) Malignant Disease of Prostate.

The only case I have to offer of this condition is an important one.

B. L., aged 69, suprapubic cystotomy performed on June 24, 1919. The
prostate was found at the operation to be malignant. This opinion was confirmed by
Dr. G. W. Nicholson, who found it to be carcinomatous. As I was fortunate enough to
get the growth out cleanly and as no obvious disease was left behind—I decided to
close the bladder. A little leakage occurred, but only a very little, and the patient was
discharged with the wound healed soundly on July 12, 1919, or eighteen days after the
operation. He died in June, 1922, three years after operation, with secondary deposits.
Between operation and death he never had any local recurrence and lived a happy life
free from pain and urinary trouble.

(Ill) Adenoma of Prostate complicated by the Presence of
Vesical Calculi.—Three Cases.

These cases, three in number, are recorded under a separate heading, as I
take it the presence of vesical calculi is indicative of damage to the bladder
mucous membrane.

Section of Urology

Of these three cases two, aged 65 and 60 years respectively, did perfectly
well and lived some years after the operation with no recurrence of local
symptoms or disease of the urinary tract. One patient, aged 69, however,
died shortly after the operation from haemorrhage and shock, chiefly associated
with the prostatectomy. Doubtless the attempt at primary union was wrong,
and its occurrence prevented the officers on duty at the hospital from doing
what they might otherwise have done in the way of controlling the haemorrhage.
The main calculus removed from this patient was a very “ spiky ” one.

(IY) Growth of the Bladder.

I do not include under this heading any case of such a malignant condition
as a true carcinoma or sarcoma, but I do include not only simple papillomata
but also those papillomata, which, clinically, tend to spread or multiply, and,
pathologically, are found to be infiltrating.

I have records of ten such cases, the average age of whom was 44i, varying
from 69 downwards to 19—four females are included under this heading.
The average stay in hospital after operation was twenty-two and a half days,
just half the average time. Five cases healed perfectly; four of the patients
are now well, and one patient has a slight papillomatous fringe at the neck of
the urethra; and this condition is manifestly improving with diathermy. In
three cases there was a trifling amount of leaking for one or two days, but
healing was otherwise perfect and the patients have done well since the
operation. In two cases the patients died. Of these two cases, one of the
deaths, that of a man aged 56, took place one week after operation from
bronchitis following a cold spell of weather in February, 1916. Post mortem :
bladder and wound perfectly healthy. The other death was, I have no doubt,
due to the suturing of the bladder. The patient was a woman, aged 38, who
was under the care of my colleague, Mr. R. Davies Colley, in Guy's Hospital.
I am indebted to him for permission to use the notes of the case.

She had passed a stone about the size of a nut some two years before admission.
She continued to pass stones at frequent intervals, and in all passed about nine stones,
which were white and brittle. She had had bladder irrigation. She was admitted
with haematuria on November 25, 1921. I examined her cystoscopically, and found, as
I thought, a papilloma in the region of the left uretreic orifice of the bladder. I
operated upon the bladder on December 16,1921, and removed the growth—the bladder
came easily into the wound, so I excised the mucous membrane round the growth.
Two or three sutures were put through the mucous membrane and the edges brought
together. I sutured the bladder and abdominal wall. She appeared to do well, but on
December 80 she suddenly became worse, and sank, and died on January 1, 1922.

Post mortem .—Pyelitis in the right kidney. A small hole in the base of the
bladder—cellulitis round the base. Pus tracking up to the left kidney, which was
infected with septic changes.

(V) Vesical Calculi.

I have only one ease to record of this condition :

Patient, aged 49, had had his right kidney removed for tubercle by Mr. C. H. Fagge,
in 1918, who, in addition to his own, was kindly doing my work at Guy’s Hospital.
This operation was quite successful. Patient in 1919 complained of pain in the bladder.
The cystoscope revealed the presence of multiple calculi. I performed suprapubic
cystotomy on March 6, 1919, and removed the calculi. I sewed up the wound as the
patient was a nervous “ jumpy ” man, and I feared that, if the wound were left open*
any tuberculous focus in the bladder, of which there was no naked-eye evidence, might

50 Thompson: Operations upon the Bladder and Prostate

become associated with sepsis. The wound healed well without leaking and patient
was discharged on March 30, 1919, twenty-four days after the operation. He did
remarkably well, but now has pyuria and hematuria with no X-ray evidence of vesical
calculus, and, I fear, tubercle of the remaining kidney.

(VI) Ketrograde Catheterization.

I have one case to record of this operation.

The patient, aged 30, had an impassable stricture of the urethra. I failed with
internal urethrotomy and at once opened the bladder. I performed retrograde catheter¬
ization, and tied.in a catheter and sutured the bladder and abdominal wall. Patient's
recovery was complete, and he was discharged twelve days after operation and has
done well since the operation.

(VII) Exploration of the Bladder.

Patient in this one case was a male, aged 65, in whom I suspected enlarged prostate.
I cut down and found nothing to warrant removal. The wound was sewn up and a
catheter inserted. I cystoscoped him on the fourteenth day and found the edges of
mucosa in the bladder separated from each other by a yellow coloured slough. The
wound, which had been median, longitudinal and straight in the distended bladder was,
in the bladder when holding 6 oz. of fluid, curved forwards, dow'nwards and to the
right. The patient was discharged apparently well on the sixteenth day after operation.
In one week’s time, he returned under my care with a small fistula in the suprapubic
region which healed up in ten days, with suitable catheterization. I traced him for a
few months and he did well. I think his medical attendant would have reported to me,
if anything untoward had happened.

The cases of attempted primary union, after suprapubic cystotomy has
been performed for various reasons, have now been dealt with in detail.
The deductions to be drawn from these records may now be discussed. The
method of operating and the treatment after operation will be considered
later.

In the cases previously cited it may be stated at once that the stay in my
beds at Guy's Hospital of primary union cases is much shorter after operation
than that of cases left to heal up by themselves. I have suggested forty-five days
as the average stay of cases of open operation. Primary suture after prostatec¬
tomy reduces the stay to twenty-nine days. Primary suture after removal of a
growth reduces the average stay to twenty-two and a half days, or exactly half
the open operation average. As in these cases of primary union the amount
of dressing used is very small compared with that of the open wounds, the
advantages accruing to the finances of a hospital are sufficiently obvious.

There is not a single case on record in my notes of a fistula persisting
more than ten days, and that only in two cases.

There is only one case of bronchial complications. That indeed was a
fatal case, but I have given reason for supposing that the bronchitis was not
due to the primary suture. I have frequently heard patients complain that
either they are afraid or they are unable to cough with the open wound.
With the closed wound I have not had any complaints of this difficulty. The
ability to cough up phlegm is of inestimable service to an old man.

The wound has never really caused me any anxiety as regards local sepsis.
There has never been undue tension upon the suture or any cutaneous septic
lesion. In fact, there can be very little doubt that the patients have benefited
greatly by the primary union operation.

There is one case of slight recurrence of a growth of the bladder at its neck,
but surely this is much better than a spread of the growth to the apex of the

Section of Urology

bladder and into the surrounding abdominal wall: I have seen this five times in
cases admitted into Guy’s Hospital, having been operated upon previously
in other hospitals. Surely the wound in such cases, if complete removal
can be reasonably ensured, should be sewn up.

I have given an account of the advantages of primary union after bladder
operations. The rules for not attempting primary union are, in my opinion,
the following:—

(1) Any wound of the base of the bladder, apart from that involved in
prostatectomy, may lead, even when sutured, to a cellulitis of the base of the
bladder and I shall be very cautious in future about sewing up a bladder
when the base has been involved in the operation, apart from the prostatic
region.

(2) I should not advise suture of the bladder in cases of enlarged prostate
associated with the presence of a rough or sharp pointed calculus. I have
four specimens of these “ spiky ” calculi coming under Class III and, I take it,
they are, therefore, not uncommonly associated with enlarged prostate.

(3) If I did not think that the patient’s pulse was good enough to warrant
my saying that there would be no reactionary haemorrhage within twelve hours
of the operation, I would not recommend suture.

(4) If I did not think that the bladder was left in a nice post-operative
state—e.g., absence of haemorrhage, with a smooth, clean and contracting
cavity after prostatectomy, I would not recommend suture of the bladder.
With advanced cystitis and uraemic symptoms, it need hardly be said I should
not recommend suture of the bladder.

As regards malignant disease, with the reservation that my first rule must
be kept in mind, I think the case I have related of B. L., aged 69 (p. 48), shows
that after removal of a malignant prostate by means of suprapubic cystotomy,
the question of primary union should be very seriously considered.

Suprapubic Operation.

The steps of the suprapubic operation may now be considered very briefly,
The patient is prepared in the usual way, and an incision is made through
the abdominal wall in the usual suprapubic position. The cave of Retzius
is exposed and the peritoneum retracted from the front and sides of the
bladder. The edges of the wound are very carefully packed round with gauze
in the undermined part lying superficial to the bladder. This packing is done
as carefully as possible. A transverse incision is made in the bladder wall and
the fluid evacuated. If it is thought that the intravesical condition demands
complete exposure of the bladder cavity the sides and upper and back part of
the bladder are gently dissected free with a finger or a blunt instrument,
or with an occasional touch of the knife, but care is taken not to tear the
tissues. The space then exposed is thoroughly packed with gauze.

After the bladder incision is made, if it be a large prostate which is to be
operated upon, this is removed in the usual way, and haemorrhage stopped by
massage of the cavity and the application of hot liquor hamamelidis at
115° F. It is surprising how far the prostatic region may be brought up into
the wound.

During the actual enucleation of the prostate the patient is under deep
chloroform anaesthesia. I have been greatly assisted in this respect by
Mr. Eric Scott and Mr. A. D. Marston, and we find that under these circum¬
stances there is much less shock to the patient during enucleation than when

52 Thompson: Operations upon the Bladder and Prostate

other methods of anesthetization are adopted. After all hemorrhage has
ceased, care being taken that the pulse is of sufficient volume to indicate
a reasonable blood-pressure, the wound in the bladder is sutured with catgut
sutures, five or six in number, applied Lembert-wise to the wall of the bladder,
care being taken to avoid the mucous membrane. The sutures are tied off
and cut close; if necessary, reinforcing Lembert sutures are applied.

Great care is taken to ensure that there is no deficiency in the union of the
bladder wall. The bladder is dropped back into place, the gauze packing is
removed, and it is surprising how the peritoneum follows it and completely
covers the site of incision in the bladder-wall. Catgut sutures are then
applied to the rectal sheath, which lies in front of the rectus muscle. The
suturing of the rectus muscle itself is avoided as far as possible. Salmon-
gut sutures are used for sewing up the skin. A catheter is passed and re¬
tained for twenty-four hours. My former house-surgeon, Mr. D. J. P. O'Meara,
who took a great deal of trouble over my cases, found that patients, both
male and female, pass their urine more frequently than might be expected
when it is removed.

One or two questions occur to me with regard to particular points in the
steps of the operation, the main details of which have just been given.

First, as regards distension of the bladder preliminary to operation. It
is very important in order to ensure primary union in suprapubic wounds
to avoid shock, which, occurring just after the operation, occurs at that
particular time when the wound is most suceptible to infection. At one
time I used to distend the bladder with air, preliminary to operation, in
order to avoid contamination of the tissues around the bladder by fluid
escaping from it after incision. But my house-surgeons did not like this
plan, and certainly there seems, for some reason, to be more shock caused
to the patient by distension with air than with warm fluid. I have
ceased to inject air, and seek to avoid contamination of the peri¬
vesical tissue, when the fluid is evacuated, by careful packing with gauze.

It would be interesting to know if others have had similar experience
with air distension of the bladder.

Secondly, the question arises as regards the direction of the incision in
the bladder.

My reasons for adopting the transverse incision in suprapubic cystotomy
are as follows:—

(1) There is less likelihood of the peritoneum being damaged by a trans¬
verse incision than by a longitudinal incision, especially if it becomes
necessary to prolong the incision. Evqn with a bladder which is very
much distended with fluid I believe that the peritoneum is constantly to be
seen and avoided.

(2) In my experience, there is less bleeding from the bladder-wall after a
transverse incision than after a longitudinal incision—the large perivesical
veins being cut right across rather than notched, as they may be with a longi¬
tudinal incision.

(3) Complete and satisfactory suture of the bladder wound is more easily
secured after a transverse than after a longitudinal incision. I find it a
difficult and rather lengthy proceeding to suture the wall of the empty bladder
in the lower part of a longitudinal wound—much more difficult than the
suture of the ends of a transverse incision.

There are special points to be considered in connexion with an operation

Section of Urology

for intravesical growths which do not, I think, occur in connexion with the
removal of an enlargement of the prostate gland.

Here I shall touch upon very debatable questions which I shall, neverthe¬
less, venture to put forward. These questions centre round the use of a re¬
tractor in bladder surgery. I find that, in females practically always, and
without much perivesical dissection, and, in males less frequently, and
with more perivesical dissection, it is possible to bring the base of the
bladder into the wound and remove growths which are situated in the base
of the bladder. I avoid the use of a retractor as far as possible. First,
because I feel that its unwise and careless use may damage the bladder-wall in
the region of the incision. Secondly, because a retractor commits one to a deep
and possibly therefore a lengthy operation. I like the growth to come to me
rather than that I should go to meet the growth in the depths of a bladder
rendered deeper by the retractor.

My plan is this, that instead of using a retractor, I place curved Lane’s
or Moynihan’s forceps upon the edges of the wound. These are applied round
the wound as symmetrically as possible, six to eight in number, and traction
is made upon them as a whole, and not upon one or two. If traction is thus
applied to the edges of the wound it is, at any rate to me, surprising that there
is no tearing of the edges of the wound. Care, however, must be taken that
undue shock is not caused by this traction upon the bladder.

I consider, also, that in those cases, in which a surgeon, especially at a
teaching hospital, can bring a growth up into the wound, he is much more
likely to remove the growth entire, and for the better instruction of students,
than if he is operating at the bottom of a deep and obscure cavity.

An advantage of primary union after an operation for vesical growth is that
there is, I think, less tendency for it to spread either locally or into the bladder-
wall along the urachus and post-part of the rectal sheath. If it does recur it
remains in the bladder and is separated from the abdominal wall by healthy
tissue.

Summary of the reasons for suprapubic cystotomy wounds being sewn up
may now be given.

Reasons fob Primary Union.

(1) The comfort of the patient.

(2) The decreased trouble of after-treatment of the case, and diminished
amount of dressings.

(3) The shorter convalescence.

(4) The greater strength of the wound resulting from the operation.

(5) The better restoration of the normal anatomy of the parts after
operation; including particularly that of the peritoneum, and the better
post-operative functionating power of the bladder muscle.

(6) The prevention of late complications, which may be associated with
an open suprapubic wound.

(7) Last, but not least, the greater care which would be exercised in a
suprapubic operation by an operator who proposed to suture the bladder after
the operation.

54 Ward: Air Embolism occurring during Urethroscopy

Case of Air Embolism occurring during Urethroscopy.

By R. Ogier Ward, F.R.C.S.

PATIENT, a man, aged 68, who had suffered from gonorrhoea forty years
previously, and had passed urine with some difficulty and in a narrowed
stream for twenty years. An unsuccessful attempt was made to pass an
instrument through a stricture in the bulb of his urethra. A week later, aero-
urethroscopy was carried out, a tightly fitting urethroscope tube was employed,
and during the introduction of this some haemorrhage occurred from the
urethral mucous membrane. After swabbing this out the examination was
continued. The urethra did not easily dilate and, in order to see the stricture,
more air pressure was employed than in ordinary cases. The patient became
dyspnoeic, cyanosed, convulsed, and then died. After unsuccessful artificial
respiration for about ten minutes, the abdomen was opened, the diaphragm
incised and the pericardium entered. Cardiac massage was employed for
another ten minutes without avail. Air could be felt in the right ventricle :
finally the wall of this was incised and frothy blood escaped.

On post-mortem examination a stricture was found in the bulb of the
urethra with small lacerations of the mucosa anterior to it. One kidney was
hydronephrotic, the other showed interstitial nephritis. All the cavities of the
heart contained frothy blood. There was no patent foramen ovale. Bubbles
of gas were also found in the aorta, common iliac arteries and the circle of
Willis ; also in the pulmonary veins, inferior vena cava, common iliac, spermatic
and cerebral veins. No froth was found in the pulmonary artery, probably
owing to the fact that the right ventricle had been incised and partly drained.
No air was found in the bladder.

The case is noteworthy because such occurrences are rare, though minor
degrees of embolism during urethroscopy are perhaps not very uncommon.
The distribution of the gas throughout the heart and throughout the circulation
is interesting. This experience emphasizes strongly the well known danger of
employing aero-urethroscopy when there is injury of the urethral mucous
membrane. The danger is certainly greater if a tight stricture prevents the
easy escape of gas into the bladder, especially if the urethroscope tube fits
closely. Finally, it may be suggested that oxygen may be usefully employed,
since there will be a far greater margin of safety should embolism occur.

Section of Virology

President—Sir John Thomson-Walker, F.R.C.S.

The Operative Treatment of Vesical Diverticula.

By J. Swift Joly, F.R.C.S.

The treatment of large vesical diverticula is one of the most difficult
problems with which the urinary surgeon has to grapple. Complete excision
of the sac is, at present, the accepted method of dealing with it, but as so
many widely divergent views have been expressed on this subject, it may
be of interest to give a brief description of fourteen cases upon which I have
operated, and the conclusions I have drawn as to the relative values of the
different methods employed.

Case I.—Male, aged 51, admitted to St. Peter’s Hospital January 11, 1910.

History : He always had difficulty in micturition, and took much longer to complete
the act than other people. Was catheterized in 1901. His bladder was then infected.
Since then he has suffered from frequent attacks of pain in the left groin, accompanied
by headache, backache, night sweats, marked frequency of micturition, and occasionally
by haematuria. Frequency of micturition from one to two hours both by day and by
night. The urinary stream was slow and weak, but he never had retention of urine.
Pain during micturition felt along the urethra.

On examination: No stricture. Residual urine 13 oz. Prostate normal; above it
the bladder bulged into the rectum, but was not indurated. The bladder could be felt,
when it was apparently empty, rising just above the pubis, under the right rectus; when
it was distended the displacement to the right was more marked.

Urine: Specific gravity 1018, acid, albumin present, no sugar, urea 1 per cent.,
deposit of pus and blood.

Cystoscopy : It was only after a long course of daily irrigation that it was possible
to wash the bladder clear enough to obtain a satisfactory view. Distention 24 oz.
The right ureter was displaced to the right, and the left almost to the middle line. The
opening of a large diverticulum was seen above and to the left of the left ureter.
It was round, and appeared to be about the size of a lead pencil. Surrounding this
orifice, except at its lower part, was a polypoid mass of cedematous mucous membrane.
The left ureter was dilated.

Operation, January 19, 1910: Trendelenburg position. Median incision from pubis
to umbilicus, and a transverse incision across the left rectus 1J in. above the pubis.
The operation was entirely extra-peritoneal. The diverticulum was about half as large
again as the bladder. It completely filled the left half of the pelvis, and extended a
short distance to the right of the middle line, pushing the bladder before it. The
diverticulum was separated from the surrounding tissues until the spine of the ischium
was reached. A large vein was torn here, and as it could not be picked up and tied,
this part of the wound was plugged with gauze. The bladder was then opened, and the
orifice of the diverticulum identified. It just admitted the first finger, and was about

Jy—U 1 [March 22, 1923.

56 Joly: The Operative Treatment of Vesical Diverticula

an inch above and to the left of the left ureter. With one finger in the opening, the
wall of the diverticulum was divided close to the bladder. This incision was carried
round the orifice, and the diverticulum was separated from the bladder. This brought
the left ureter into view. It was about as thick as the finger, and curved forwards,
immediately below the diverticular orifice to its entrance into the bladder. In this
portion of its course it was compressed between the diverticulum and the bladder.
The diverticulum was now rapidly freed from the remaining adhesions to the rectum
and prostate, and removed. The bleeding points were picked up and ligatured, the
wound partially closed, and the bladder and pelvis drained.

The convalescence was slow, and a suprapubic fistula, which tracked down to the
diverticular opening, persisted for almost three months. It then closed, but after
a short time broke down again. On June 8, he was again admitted to hospital, and the
sinus excised, at the same time the prostate was enucleated, though it did not appear
to be enlarged, as it was thought to have been the cause of the persistent sinus. After
this operation the fistula remained closed. In 1918 he was again admitted to hospital,
and a suprapubic hernia was cured by the filigree method.

This patient eventually died in December, 1920, almost eleven years after his
operation, of chronic pyelonephritis, which persisted in spite of treatment. During this
interval he had practically no frequency or difficulty in micturition, but there was
always about three ounces of residual urine.

The diverticulum, after it was hardened, was about the size of a large orange.
Its walls were £ in. thick, and were composed of three distinct layers of muscular
tissue, lined with transitional epithelium, which was much altered by inflammation.

Case II.—Male, aged 53, admitted to St. Peter’s Hospital March 19, 1912.

. History: Gonorrhoea thirty years before. Developed a stricture, w r hich was easily
dilated. Passed a bougie on himself twice a year, but the second time he did so he
infected his bladder. Since then had several attacks of cystitis, and his urine always
remained turbid.

On admission : Slight frequency of micturition. Stream good ; some straining
towards the end. Occasionally micturition a deux temps. Stricture admitted 17 F
easily, and was fully dilated in two sittings. Prostate normal, but a soft elastic
swelling could be felt above it. Residual urine varied from 12 to 16 oz.

Urine : Specific gravity 1018, acid, no albumin nor sugar, urea 1’9 per cent., deposit
pus and bladder epithelium.

Cystoscopy: Slight general cystitis. Both ureters normal, clear efflux from both
sides. Above the interureteric bar and immediately to the left of the middle line was
the opening of a large diverticulum. It was oval in shape, with the long axis directed
vertically. The cystoscope was introduced into the diverticulum. Its walls were
a deep red colour, smooth, and no vessels were visible.

Operation, March 22, 1912 : Trendelenburg position. Bladder washed out, emptied
as much as possible, and distended with air. Median incision from pubis to umbilicus,
peritoneum opened. The diverticulum appeared like an immense bleb on the
posterior wall of the bladder, to which it was adherent over a circular area about
3 in. in diameter. The bladder w'as then opened, and it was found that the diverticulum
was completely filled with a mixture of urine and lotion. This was mopped up.
As it was impossible to find any line of cleavage between the bladder and diverticulum,
the former was split from front to back. The posterior part of this incision surrounded
the orifice of the diverticulum, which was excised. The whole of the epithelial lining
of the diverticulum was then removed, also the greater part of its outer wall, only two
peritoneum-covered flaps large enough to cover the raw surface being left. These were
stitched in place, and the bladder wound sutured except for a small space left for
a drainage tube. The peritoneal cavity was then closed, and the abdominal walls
sutured.

The ureters first passed downwards between the bladder and the diverticulum, then
backwards beneath it, and finally upwards along its posterior surface. They formed
ridges visible on the inner surface of the sac, and divided its lower portion into three
pouches, a median and two lateral. The deepest portion of the diverticulum reached

Section of TJrology

the level of the middle of the prostate. Its walls were very thin, and were composed of
a single sheet of muscular tissue lined by epithelium.

The patient bore the operation well, and left hospital in four weeks, with his wound
firmly healed. He returned in three months with a urinary fistula in the scar. He was
admitted and the fistula was excised. Since then he has had no further trouble.

He was lost seen about two years ago. There was no frequency of micturition*
The urethra admitted a No. 26 F instrument easily.

Cystoscopy : Slight general cystitis. A puckered scar occupied the site of the old
diverticular opening; from this a linear ridge ran forwards to the apex of the bladder.
Residual, 2 oz. The urine was slightly cloudy, and contained pus and colon bacilli.

Both these cases have already been reported [l] :—

Case III.—Male, aged 49, admitted to St. Peter’s Hospital September 2, 1912.

History: Patient was treated for stricture twenty years before. In 1901 he was
sounded for stone, but none found. Since then he had an attack of hsematuria about
every six months. For the last few months haemorrhage at the end of almost every act
of micturition. Old standing cystitis and pyelonephritis.

Present state : Frequency, every hour by day, six or seven times at night. Stream
fair, precipitancy, never retention.

Urethroscopy: No stricture. Residual urine, 11 oz. Prostate normal.

Cystoscopy: Intense cystitis, especially on the base of the bladder. Ureters not
visible. Opening of a large diverticulum near fundus, just to the left of the air bubble,
and of a smaller one to the right of the middle line on the posterior wall.

Urine : Specific gravity 1010, alkaline, albumin present, no sugar, blood small
quantity, urea 1*8 per cent., sediment muco-pus.

Operation, October 4, 1912: Bladder washed out, and distended with air. Supra¬
pubic incision, bladder exposed. Patient then put in Trendelenburg position, and
peritoneum opened. Diverticulum at the apex of the bladder, running up into the
urachus. Peritoneum stripped off the upper surface of the bladder, and off the
diverticulum. Peritoneal cavity then closed. Bladder opened in the middle line,
incision prolonged upwards so as to surround diverticular opening. Urachus clamped
and divided half way between the pubis and umbilicus, and diverticulum removed.
At this point the urachus was found to be patent, and filled with faeculent looking
material. It was followed up to the umbilicus, and entirely removed. Bladder sutured
round a large tube, and the abdominal wound closed. The diverticulum on the
posterior wall only admitted the tip of the index finger, and was not removed.

Patient died, on the twentieth day after operation, of chronic pyelonephritis.

Case IV.—Male, aged 61, admitted to St. Peter’s Hospital March 10, 1915.

History : Had been treated for stricture on and off for thirty years. Urethroscoped
in the out-patient department and no stricture found. Had a poor urinary stream
all this time.

Present state : Frequency of micturition, every two horns by day, twice at night.
Stream poor, straining, stream often interrupted, no precipitancy. Patient had
numerous attacks of retention which necessitated catheterization. No pain, except
slight scalding on micturition.

Cystoscopy: No cystitis, both ureters normal. Orifice of a fair sized diverticulum
above and to the outer side of the right ureter. Prostate slightly enlarged. Residual
urine, 2 oz.

Urine: Clear, acid, specific gravity 1018, no albumin nor sugar, urea 1*7 per cent.,
no deposit.

Operation, March 12, 1915 : Trendelenburg position. Usual suprapubic incision.
Diverticulum found to be about the size of a walnut. Freed from adhesions outside the
bladder, invaginated into it, and cut away. Gap in the bladder w*all sutured with
continuous catgut. Prostate enucleated. Bladder closed round a large tube, lateral
space drained.

During convalescence patient developed double epididymitis. Discharged May 9,

58 Joly: The Operative Treatment of Vesical Diverticula

1915. Wound firmly healed. Urine clear, no residual. Frequency, four hours by day,
once at night.

Case V.—Male, aged 68, admitted to St. Peter’s Hospital April 14, 1915.

History : For five years frequency of micturition, sometimes every half-hour.
Suprapubic lithotomy, March, 1914 ; passed stones soon after his return home.
Passed as many as thirteen in one day. Litholapaxy September, 1914, and again
in October, 1914. Passed more stones after both these operations.

On admission: Frequency every three or four hours by day, twice at night. Stream
good, but often interrupted, some urgency, no incontinence. No hsematuria.

Urine : Turbid, offensive, alkaline, specific gravity 1018, albumin present, urea
1*8 per cent., much ropy muco-pus.

Bladder intolerant, cystoscopy impossible.

Cystogram: Bismuth suspension. Diverticulum size of a hen’s egg on right side
of bladder. Long narrow neck.

Operation, April 16, 1915 : Trendelenburg position. Old scar excised. Peritoneum
opened. With the help of a finger in the peritoneal cavity, the peritoneum was
stripped off the bladder. Opening in peritoneum sutured, and the bladder opened. A
loose stone was removed. Diverticulum found to be packed with calculi, which were
removed. It was about the size of a hen’s egg, and extended downwards to the base
of the bladder. The ureter curved downwards and forwards, first behind and then
below the orifice of communication. The diverticulum was very adherent, but was
freed and removed from outside the bladder. Gap in bladder wall closed with two
layers of continuous sutures. Prevesical space and bladder drained, rest of wound
sutured. The orifice of the diverticulum just admitted the index finger. It was
about half an inch above and to the outer side of the right ureter.

Convalescence uneventful. Patient discharged on May 26, 1915. Wound soundly
healed. No frequency of micturition. Urine still turbid. No residual.

Case VI.—Male, aged 72, admitted to St. Peter’s Hospital September 1, 1915.

History: Frequency of micturition and straining for three years. Prostatectom> r
January, 1914. Was treated for cystitis March and April, 1914. His condition
improved for a few weeks, then grew steadily worse.

On admission: Frequency every ten minutes by day, every forty-five minutes by
night. Stream dribbling, great straining. Occasionally passed clots. Severe pain
along the urethra during micturition.

Urine : Turbid, ammoniacal, urea 1*4 per cent., much muco-pus, albumin present.

Cystogram: Bismuth suspension. Bilateral diverticula, each about the size of a
walnut standing well out from the bladder.

Operation, September 3, 1915 : Trendelenburg position. Old scar excised. Bladder
very adherent to surrounding structures, especially to the posterior surface of the pubis.
Adhesions divided, and bladder opened. The orifices of the diverticula were sym¬
metrically placed, each about an inch above and to the outer side of the corresponding
ureter. Bladder wall split down to the orifices, and the diverticula dissected free, and
removed. Bladder wound closed round a large tube, and each lateral space drained.
The whole operation was rendered difficult and tedious on account of adhesions.

Patient discharged from hospital, September 29, 1915. Wound firmly healed ;
frequency two hours by day and night. Attended the out-patient department for a few
months; during that time his urine became clear, and the frequency of micturition
abated.

Case VII.—Male, aged 49, admitted to St. Peter’s Hospital June 20, 1916.

On admission : Frequency of micturition eight to ten times during the day, twice at
night. Pain along the urethra during the act. No stricture, no enlargement of the
prostate.

Urine: Bacilluria, no albumin nor sugar, urea 1*1 percent. Residual urine, 9 oz.

Cystoscopy: Base of bladder, and all round the internal meatus cedematous.
Opening of a diverticulum just above and to the inner side of the right ureter. Ureteric
orifices normal in appearance.

Section of Urology

Operation, June 23, 1916 : Trendelenburg position. Bladder widely opened. Diver¬
ticulum admitted index finger to a depth of almost 3 in. Incision round orifice, and
diverticulum freed by blunt dissection. A quarter-inch tube passed through the bladder,
and into the space from which the diverticulum had been removed. Gap in bladder
sutured round it. Bladder drained.

Patient discharged August 4, 1916. Wound healed, no residual, no frequency.

Case VIII.—Male, aged 71, admitted to St. Peter’s Hospital August 23, 1919.

History : Fifteen years before had some difficulty in passing urine for three or four
days. Well until April, 1919, when sudden retention of urine occurred, followed by a
severe fit of shivering. Catheterized. Since then on complete catheter life, passing
the instrument three or four times a day, and once at night. Previous to April, 1919,
frequency every two hours by day, and every hour by night.

On admission: Decidedly senile. Per rectum , prostate not enlarged. Cystoscopy.
Slight intravesical projection of prostate. In the neighbourhood of right ureter, round
orifice of an enormous diverticulum. Orifice about the size of a shilling, cavity very
dirty. Bight ureter could not be seen ; left, normal in position. Severe general cystitis.

Cystogram : Thorium solution. Oblique position showed a double cavity, with the
diverticulum low down in the right side of the pelvis. It was about the same size as
the bladder. Antero-posterior position, showed cavity overlapping bladder, and extending
far to the right.

Urine: Specific gravity 1010, acid, albumin and sugar present, urea 0’3 per cent. ;
183 gr. passed in the twenty-four hours.

Operation, September 5, 1919 : Stovaine. Trendelenburg position. Median incision
from pubis to umbilicus, bladder widely opened. With the hand in the bladder, the
finger could just reach to the bottom of the sac. An attempt was made to invaginate
the diverticulum into the bladder, by blunt dissection from without, aided by traction
by means of a volsellum passed through the orifice. Dense adhesions binding the sac
to the seminal vesicles, prostate, and rectum made it impossible to complete this
invagination ; however the upper wall of the diverticulum was completely invaginated.
A semicircular incision was then made, severing the upper portion of the neck of the
sac, and the diverticulum was inverted through this opening. This made it possible to
reach its outer wall, and the surrounding tissues were then easily separated off by means
of gauze dissection. The whole of the diverticulum was by this means turned inside
out, and invaginated into the bladder. It was so large that more than half of it came
through the abdominal wound. As the vesical orifice of the right had never been
identified, the ureter itself was exposed in the pelvis and opened. A catheter was
passed down it, and appeared between two folds of mucous membrane, just within the
diverticulum, opposite the lowest point of the opening. The sac was then cut
away, except for a small semicircular flap surrounding the ureteric orifice. This
flap was stitched over the defect in the bladder. The ureter was sutured, and the
bladder wound closed round a large tube. The lateral vesical space was drained, and
the abdominal wound closed round the tubes.

The patient bore the operation well, but convalescence was slow. The suprapubic
sinus closed after a catheter had been tied in for a fortnight. Patient sent to a con¬
valescent home October 25, 1919. Wound healed, but patient entirely dependent on his
catheter.

Readmitted April 10, 1920. On catheter life since operation. Prostate, lateral
lobes slightly enlarged, smooth, and movable. Cystoscopy. Shallow depression at
site of diverticular orifice. Small intravesical projection of middle lobe of prostate.
Severe chronic cystitis.

Urine : Specific gravity 1020, acid, small quantity of albumin, moderate quantity
of sugar, cloudy yellow colour, deposit of mucus. Phenol-sulphone-phthalein (intra¬
venous injection) appeared in three minutes; 44 per cent, excreted in the first half
hour, and 11 percent, in the second. Urea concentration test: 1*9 percent, in the
second hour, and 1*7 per cent, in the third.

Prostatectomy, April 23, 1920: Stovaine. Bladder opened after it had been freed
from the pubis. Peritoneum pushed upwards from the scar. Small prostate easily
enucleated. Very little bleeding.

60 Joly: The Operative Treatment of Vesical Diverticula

Patient discharged May 18, 1920: Wound healed. Frequency, two hours by day,
twice at night. Residual urine, 1 oz. Urine turbid. He attended the out-patient
department for a few months. General condition improved very much. Frequency,
normal.

I heard from this patient on March 20, 1928. General health good. No retention.
Frequency, four hours by day, three times at night. Stream good, urine clear. No
pain. No leakage through scar.

Case IX.—Male, aged 50, admitted to St. Peter’s Hospital December 28, 1920.

History: Difficulty in micturition for twelve months, which was steadily getting
worse. Frequency, every hour by day, not at all during the night. Had cystotomy
done one month before for over-distension, told he had a large pouch in his
bladder.

On admission: Suprapubic sinus, through which all the urine came. Urine very
foul, sinus surrounded by unhealthy granulations. Prostate slightly enlarged, hard
nodule right lobe, whole gland movable.

Cystotomy December 81, 1920: Sinus enlarged, opening of a large diverticulum
found just outside right ureter. Bladder very foul, almost pure pus coming from
diverticulum. Tube inserted into sac, and another into bladder. Daily irrigations.

Excision of diverticulum, January 14, 1921: Stovaine and general anaesthesia.
Trendelenburg position. Bladder widely opened, and freed from adhesions. Contents
of diverticulum still very foul. Diverticulum freed from surrounding structures,
invaginated into bladder and removed. Operation very difficult on account of dense
adhesions. Gap in bladder sutured. Suprapubic wound closed round large tube.
Lateral vesical space drained.

March 18, 1921: Patient discharged. Slight suprapubic leak. Passing urine freely
and without pain.

June 21, 1921: Readmitted. Double pyelonephritis. Sinus enlarged, de Pezzer
tube inserted. Patient sent to infirmary.

(As I was out of town, I did not see this patient on his readmission.)

CaseX. —Male, aged 51, admitted to St. Peter’s Hospital June 26, 1920.

History : Frequency of micturition for two years, gradually getting worse. Diffi¬
culty in micturition for one year. Ten weeks before admission complete retention.
Metal catheter passed under general anaesthesia, but as it could not be passed a
second time a perineal section and suprapubic cystotomy was performed. A diver¬
ticulum was then discovered. Bladder drained for ten weeks “ in the hope that the
diverticulum would contract.” Venereal disease denied.

On admission: Suprapubic and perineal fistul®. Most of the urine came through
the former opening. Per rectum: prostate not enlarged. In the region of the left
seminal vesical a soft, elastic, sausage-shaped tumour was felt. It appeared to be
adherent to the pelvis.

Urine: Specific gravity 1020, cloudy yellow, acid, albumin present, no sugar,
deposit of pus. Urea concentration test, 1*65 per cent, in the second hour.

July 2, 1920 : Stovaine. Urethra easily dilated to 14/16. 22 F. catheter tied in.

Perineal wound allowed to heal.

Cystotomy, July 28, 1920 : Stovaine and ether. Scar excised, and bladder opened.
Diverticulum discovered on the left side. Opening about an inch above and to the
outer side of left ureter. It easily admitted the index finger. Cavity very large,
about the size of the clenched fist, was filled with exceedingly foul pus. Tube
inserted into diverticulum and another into the bladder. Wound partially closed.

Continuous irrigation was attempted, the fluid entering through the tube in the
diverticulum and returning by the bladder tube, but it failed, as the diverticular orifice
contracted round the tube placed in it, and did not allow the fluid to circulate.

Excision of diverticulum, July 28, 1920: Stovaine, and ether after the first hour.
Cystotomy wound reopened. Bladder wall very thick and indurated, and this made it
difficult to expose the interior of the viscus. Much pericystitis. Left lateral wall
split down to the diverticular orifice. Sac very adherent; was tom during removal,
but the whole of it was got away. Peritoneum twice torn and sutured. Left ureter

Section of Urology 61

localized, and kept from injury. Left vas cut across. Bladder sutured round a large
tube. Lateral space drained.

Fowler position, Murphy’s rectal drip.

Patient discharged from hospital August 80, 1920. General condition good.
Wound soundly healed. Urine acid, slight deposit of pus. Could hold urine for two or
three hours. Residual less than 1 oz.

March 80, 1928: 1 heard from this patient. General health fair. Frequency by
day six times, once at night. Urine clear. No pain. ’ Stream fair. No leakage
through wound.

Case XI.—Male, aged 58, admitted to St. Peter’s Hospital March 4, 1922.

History: Since 1915 frequency of micturition, later difficulty and straining.
Urgency and some incontinence for three years. For four months has catheterized
himself every day, but was able to pass a small quantity of urine naturally.

On admission: No stricture. Prostate slightly enlarged, soft, elastic, could be felt
bimanually, freely movable.

Cystoscopy: Residual urine 9 oz. Very marked trabeculation. Numerous small
saccules. Diverticulum on right side, at junction of posterior and lateral walls. Stone
in post-prostatic pouch. Ureteric orifices not seen on account of intravesical projection
of middle lobe of prostate. No cystitis.

Urine: Clear, acid, specific gravity 1017, no albumin nor sugar; daily urea, 1*8 per
cent.; urea concentration test, 8 per cent.

Cystogram: Sodium iodide solution. Large diverticulum right side, long narrow
neck. Numerous small saccules especially near the base of the bladder.

Operation, March 15, 1922: Suprapubic incision. Calculus removed. Bladder
wall very thick, much pericystitis. Bladder wall split down to orifice of diverticulum,
and sac excised. Right ureter and vas adherent to it. Prostate enucleated, and
prostatic cavity packed with gauze. Wound in bladder sutured round a half-inch tube.
Small tube in lateral space. Wound closed.

April 15, 1922 : Patient discharged from hospital. General condition excellent.
Suprapubic wound healed, passing water freely per urethram.

This patient was seen on February 26, 1928. Frequency four hours by day,
occasionally once at night. Residual urine l£ oz. Urine slightly cloudy. General
condition very good.

Case XII.—Male, aged 37, admitted to St. Peter’s Hospital, April 1, 1922.

History: Eighteen months before, pain in the hypogastrium, w'hich had no relation
to micturition. Six months later frequency and difficulty in micturition. Frequency
then seven or eight times by day, twice or three times by night. Stream poor, only a
small dribble, urgency. April, 1921: Acute retention, lasted two days ; similar attack
next month. July, 1921: Suprapubic cystotomy for stone, but none found. Since
then had passed a catheter once or twice a day on himself.

On admission : Weak suprapubic scar, which broke down from time to time, and
leaked urine. Bladder easily palpable when distended. Catheter life. Prostate
normal.

Cystoscopy: Distention 22 oz. Chronic cystitis especially in region of trigone.
No trabeculation. Two diverticula : (1) Just above and to the outer side of the left
ureter; contents turbid, orifice about the size of a lead pencil. (2) Small one just
above right ureter. Trigone displaced to right so that the left ureter lay almost in the
middle line. Both orifices normal. (Edematous mucous membrane round orifice of
large diverticulum. Both ureters catheterized. Clear urine from both kidneys. Urea
concentration test: Both kidneys gave 8 per cent, concentration. Same test applied
to bladder urine gave 1*42 per cent. Internal urethral orifice normal.

Cystogram : Sodium iodide solution ; 20 oz. of fluid injected. Bladder displaced to
the right. Very large diverticulum filling up left half of true pelvis. Bladder emptied
as much as possible by catheter, and second exposure made. Diverticulum still
distended, and a small amount of fluid in the bladder itself.

Urine : Turbid, alkaline, no albumin nor sugar; daily urea, 1*8 per cent, in 50 oz.,
or 806 gr.

62 Joly: The Operative Treatment of Vesical Diverticula

Operation, April 19, 1922 : Left ureter catheterized. Trendelenburg position.
Scar excised, bladder freed from pubis and opened. Diverticulum freed by blunt
dissection, and gradually invaginated into bladder. Left ureter lay behind and below
neck of sac, and was separated off. Diverticulum removed together with a small
portion of bladder wall surrounding neck. Gap in bladder sutured. Lateral space
drained, large de Pezzer tube in bladder. Wound closed. Diverticulum on right side
too small to admit tip of finger, not removed.

May 8, 1922 : Patient, discharged from hospital. Wound healed. Micturition
normal. Frequency three hours by day, once at night. Residual urine 14 oz.

March 20, 1923 : I heard from this patient. General health steadily improving
since operation. Frequency three or four times by day, twice by night. Stream
44 splendid.” No pain. Wound soundly healed.

Case XIII.—Male, aged 62, admitted to St. Peter’s Hospital January 5, 1923.

History: Ten years ago heematuria after straining at stool. Since then pain 44 in
the bladder” whenever he has a cold, and occasionally a trace of blood in the urine.
Five years later frequency and difficulty in micturition. Soon afterwards catheter life,
passing the instrument twice or three times a day. Cystoscoped in 1912, and told
“he had a sac.” Admitted to St. Peter’s Hospital October 20, 1919. Prostate
removed. Discharged December 27, 1919. Had intense cystitis at the time, and
diverticulum apparently not noticed on cystoscopy. Suprapubic wound took twenty-
two months to heal. Patient washed his bladder out every day with nitrate of silver
by Janet’s method. Had slight hsematuria shortly after leaving hospital, and passed
several small stones.

On admission: Frequency of micturition six times by day and twice at night.
Micturition normal, stream and projection both good. Abdomen: Suprapubic scar,
weak in its lower portion. When bladder was distended, it could be feit in right iliac
fossa. Right kidney not palpable, left completely palpable, movable, enlarged,
painless.

Cystoscopy: Residual urine 30 oz. Bladder capacity 50 oz. Generalized cystitis
with irregular bulging and sacculation. Right ureteric orifice active, fairly healthy;
left large, patent, never closes. Opening of diverticulum fairly high up on the left¬
side, difficult to see because left wall of bladder was pushed almost to middle line by
the diverticulum. It appeared to be about the size of a sixpenny piece.

Cystogram: Sodium iodide, 5 per cent, solution; 48 oz. injected. Enormous
bladder pushed over into the right iliac fossa. Diverticulum filled left side of true
pelvis. Small slit-like space between bladder and diverticulum. Narrow orifice of
communication. When bladder had been emptied as much as possible by means of a
catheter, diverticulum remained nearly full, and there was still some fluid in the
bladder itself.

Urine: Hazy, specific gravity 1012, alkaline, no albumin nor sugar; daily urea,
1 per cent, in 76 oz., or 322 gr. Urea concentration test, 1’5 per cent, in 3*5 oz., or
22 gr.

Operation, January 10, 1923 : Old scar excised, and bladder opened. Trendelenburg
position. Orifice of diverticulum about I in. in diameter, situated about 1 in. above
and to outer side of left ureter. Catheter passed up left ureter. Diverticulum freed
by finger and gauze dissection, and removed from outside the bladder. Gap in wall
sutured by two layers of continuous catgut sutures. Internal urethral orifice about the
size of a lead pencil, but was incised as there was a 44 shelf ” above prostatic cavity.
Marion’s tube in bladder, lateral space drained. Wound closed, catheter tied in.

Patient discharged from hospital February 19, 1923. Wound firmly healed.
Micturition normal, no frequency. Residual urine 4 oz.

I saw this patient on March 12, 1923. General condition excellent. Micturition
normal. Frequency four hours by day, once at night. Urine clear, a few small
flakes in it.

Case XIV.—Male, aged 69, admitted to St. Peter’s Hospital January 7, 1923.

History : Three years ago difficulty in starting micturition. A few months later

Section of Urology

pain at tip of penis before and during act. Nocturnal frequency for eighteen months.
Complete retention two years ago.

On admission: Bladder distended to umbilicus. Micturition, much straining, delay,
and pain. Stream in drops only, some after dribbling. Prostate only slightly
enlarged, rather firm. No stricture. Put on regular catheterization, 18 oz. being
drawn off each time the instrument was passed.

Urine: Turbid, alkaline, specific gravity 1022, no albumin nor sugar, much pus
daily urea, 2*5 per cent, in 30 oz., or 327 gr.

No cystoscopy when in hospital on account of over-distention.

January 10, 1923 : Suprapubic cystotomy. Trivial intravesical projection of prostate.
Diverticulum size of a hen’s egg, above and to the outer side of left ureteric orifice. De
Pezzer tube inserted.

January 24, 1923: Diverticulum excised from outside bladder. It was very
adherent. Gap in bladder wall sutured with two layers of continuous catgut. Some
thick perivesical fat sutured over opening. Prostate, size of a cherry, enucleated. It
was fibrous, and contained several small calculi. Cavity packed. Marion’s tube in
bladder. No tube in lateral space.

Sharp attack of secondary haemorrhage fourth day. February 5, 1923: Large
abscess left side of bladder; tube inserted. Since then did well. March 7, 1923:
Passed urine naturally, but fistula not quite closed. March 20, 1923: Still in
hospital.

The Relative Values of the Different Operative Methods.

It is universally admitted that the only satisfactory treatment of this con¬
dition is excision of the sac, but there is a considerable divergence of opinion
as to the best method of performing the operation. However, before discussing
this question, I wish to point out the dangers of a preliminary cystotomy in
these cases. A cystotomy does not drain the diverticulum. When the bladder
contracts round the cystotomy tube, the diverticular orifice closes, and the
cavity is completely shut off from the bladder. Under these conditions no
amount of vesical irrigations will disinfect the diverticulum, and its contents
invariably suppurate. The deplorable condition that patients Cases IX and X
were in when I first saw them was undoubtedly due to this cause. In both
cases I tried to control the suppuration within the diverticulum by passing a tube
into the sac through its vesical orifice. But in neither case was it possible to
wash out the sac into the bladder, or the bladder into the sac. Both cavities
could be washed out independently of the other, but this was not satisfactory,
and in both cases I was forced to operate while the sac was still in a filthy
condition. The walls of these sacs have practically no power of con¬
traction, and remain in an inert flaccid condition, which predisposes them to
stagnation and infection. When I am called upon in future to deal with
such grossly infected diverticula, I shall, as a preliminary to excision, open the
bladder, and pass two small tubes into the sac, as well as leaving a larger
one in the bladder itself. Continuous irrigation can then be carried out, the
fluid entering the diverticulum by one small tube, and leaving it by the
other. It is, in many cases, possible to drain the diverticulum inde¬
pendently of the bladder, but I do not see any advantage in this procedure.
If the diverticulum lies below, and behind the bladder, it can only be satisfac¬
torily reached from the perineum, and this perineal drainage may render
subsequent removal of the sac exceedingly difficult, if not impossible. I
consider that a preliminary cystotomy should not be done, except when the
kidneys are damaged so severely that it is obvious that the patient would
not stand a primary excision. Even in these cases the bladder should only be

64 Joly: The Operative Treatment of Vesical Diverticula

drained for as short a time as possible, and means must be taken to drain and
irrigate the diverticulum independently of the bladder.

Turning to the operation of excision, I feel that no set operation is suitable
for all cases, but I think there are certain broad indications which would lead
the surgeon to choose beforehand the operation best suited to the particular
case. I also feel that it is not always possible to institute a definite plan
of campaign until the bladder has been exposed, as so much depends on the
amount of pericystitis present, and on the number and density of the adhesions
binding the diverticulum to neighbouring structures. One can learn the size
and position of the orifice, the amount of trabeculation of the bladder wall,
and the severity of the infection, by means of cystoscopy; and the size,
position, and to a certain extent the relationship of the diverticulum, by
means of cystograms; but one has no means of telling beforehand whether
the sac is bound down by adhesions, or lying free in the fatty tissue of
the pelvis.

With regard to the operation itself. Diverticula may be excised (l) from
the outer surface of the bladder, (2) by splitting the bladder wall down to the
orifice of the diverticulum, and (3) from within the bladder.

(1) Excision from without the Bladder .—This operation is best suited for
diverticula situated high up on the lateral walls of the bladder, and for those
occurring at the urachus. The operation may be either trans- or extra-
peritoneal. A transperitoneal operation is indicated if the orifice of the
diverticulum lies above the line of reflection of the peritoneum from the bladder
wall, but these cases are not common, as the orifice is usually situated well
below this level. In some cases it is a help to open the peritoneum when
stripping it from the upper wall of the diverticulum, but if this is done the
bladder should not be opened until the abdominal cavity has been again closed.
I have performed this operation on five of my cases (Nos. I, III, V, XIII, XIV),
in two of them (Nos. Ill and V) I opened the peritoneum to facilitate stripping
it back from the wall of the sac. The operation is facilitated if the bladder is
opened, and one finger placed in the diverticulum, while the upper and outer
walls of the sac are cleared by gauze dissection. When dealing with the lower
portion of the diverticulum, the finger in the sac is of no further assistance.
The wall of the diverticulum is then grasped low down by means of a volsellum,
and aided by traction on it the dissection is completed. I have not found it
any advantage to plug the sac with gauze, and if the diverticulum lies low down
in the pelvis, it is a positive disadvantage. The plug fills up almost the whole
of the narrow space one has to work in, and renders the dissection much more
difficult. I have tried this method on several occasions, and always had to
remove the gauze again in a few minutes. This operation is rendered difficult
if the bladder walls are thick and indurated, if the diverticulum is also thick
walled, and if there is much pericystitis.

(2) Splitting the Bladder Wall down to the Orifice of the Diverticulum .—
This operation was first described by me in a paper read before the Urological
Section of the Seventeenth International Congress of Medicine, which met in
August, 1913 [2], and quite independently by Marion in November of the
same year [3]. However in my case the operation was transperitoneal, while
in Marion’s it was extraperitoneal. The idea underlying both these operations
was the same, and was an attempt to obtain better exposure of the deeper
parts of the diverticulum. I performed this operation in Case II (trans-
peritoneally), and in Cases VI, X, and XI (extraperitoneally). Case VI was
one of bilateral diverticula, and both sides of the bladder were split down to

Section of Urology

the necks of the diverticula. The incision is really a racquet, with a long
handle and a small blade, as the orifice of the diverticulum is encircled
and a small portion of the bladder wall removed with the sac. The
operation is indicated (1) in cases in which the diverticulum is situated low
down on the posterior wall of the bladder, (2) when the walls of the bladder or
diverticulum are thick and inelastic, and (3) when there is marked pericystitis.
Case II came under the first category, and I do not think I could have
removed this diverticulum by any other means. In Cases VI, X, and XI,
troublesome adhesions were present, due in the first case to a previous pro¬
statectomy, in the second to a prolonged suprapubic and perineal drainage, and
in the third to marked pericystitis. In Cases VI and XI the bladder walls
were very thick. A rough estimate of the thickness of the bladder wall can
sometimes be obtained by means of a simple cystogram. In every case of
vesical diverticulum I have seen, the walls of the bladder and of the diverti¬
culum are in contact with each other round the diverticular opening. This
means that the length of the neck of the diverticulum is equal to the com¬
bined thickness of these two walls, so that if the diverticular shadow lies at a
considerable distance from that thrown by the bladder, and the two are only
connected by a long isthmus, it is fairly safe to assume that the bladder walls
are thick. I may also add that the walls of the bladder are always thicker
than those of the diverticulum.

(3) Intravesical Operations .—(a) Encircling the orifice by an incision
through the whole thickness of the bladder wall, and removing the diver¬
ticulum by blunt dissection. I have only performed this operation once
(Case VII), and have completely given it up, as I consider it dangerous. It is
only suited for small diverticula, and it is dangerous, because there is great
risk of wounding the ureter, which always lies in close relationship with the
neck of the diverticulum.

(b) Invagination of the Sac. —This operation should be performed partly
from inside the bladder, and partly from outside it. It is a dangerous pro¬
cedure to insert a volsellum through the diverticular opening, seize the fundus
of the sac, and attempt to invaginate it. One operator drew a loop of small
intestine into the bladder by this method, but fortunately discovered his
mistake before dividing the neck of the sac. If it is decided to remove a
diverticulum by this method, the upper wall of the sac should first be cleared
as far as possible from the outer side of the bladder, and also from the sur¬
rounding structures. This portion of the diverticulum should then be invaginated
through the orifice, and seized from within. The dissection can then be com¬
pleted from without, while traction is made by means of a volsellum gripping
the portion already invaginated. This operation is only suitable for thin-
walled diverticula, that are comparatively free from adhesions. Young employs
suction to invaginate the diverticulum [4]. This method requires an electric
pump, as the suction obtained by means of a Sprengel’s pump is quite insufficient
for the purpose. I have performed the operation of invagination in three
cases (IV, IX, and XII); I attempted it in Case XIII, but was unable to
complete the invagination, so I turned the sac back, and removed it from
outside the bladder.

(c) Combined Invagination and Inversion of the Sac. —This operation has been
fully explained when describing Case VIII (p. 59), so I need not recapitulate it.
I believe this method has not been described before, and I consider it a definite
advance on the usual invagination method. As a matter of fact I failed to

66 Joly: The Operative Treatment of Vesical Diverticula

invaginate the sac in this case, and I think I would have been unable
to remove the diverticulum if I had not thought of inverting it. It can be
employed in diverticula springing from any part of the bladder, but is
particularly useful for dealing with large sacs situated deep down in the pelvis.
It is eminently safe, as the outer surface of the diverticulum is well seen while
the adhesions are being separated from it. Of course, it cannot be employed
in cases in which the wall of the sac is too stiff to allow of invagination, but
this is the only definite contra-indication.

Operative Treatment in Cases complicated by Enlarged Prostate.

Cases of vesical diverticula have frequently been diagnosed as enlargement
of the prostate, and the gland has been removed before the presence of the
diverticulum was suspected. This happened in Cases VI and XIII of my
series. I feel that in both these cases the patient’s condition was rendered
worse by this procedure. I have already alluded to the bad results obtained
in cases where the bladder has been simply drained, and everything I have
said regarding cystotomy applies with equal force to prostatectomy. I feel
that the ideal procedure is to remove both the diverticulum and the prostate at
the same sitting. This was done in Cases IV, XI, and XIV, with excellent
results. If, however, it puts too great a strain on the patient’s powers of
recuperation, the diverticulum should be removed at the first sitting, and the
prostate enucleated as soon afterwards as is feasible. This course was followed
in Case VIII. Lastly, if the patient’s condition is so poor that he will not
stand any major operation, the bladder should be opened, and independent
drainage provided for the diverticulum in the manner already described.
Even under these circumstances, the preliminary drainage should be of as
short a duration as possible.

Vesical Diverticula complicated by Stone.

(1) Calculus lying free in the Bladder .—The mere removal of such a stone
is never a complete operation. There may be others in the diverticulum.
Even if there are none, the diverticulum remains, and will probably give rise
to symptoms. I do not think that a litholapaxy should ever be performed in
cases where there is a definite diverticulum. A case on which I operated some
years ago illustrates this point. The patient had a stone about tbe size of a
filbert lying free in his bladder, and on cystoscopy a small shallow diverticulum
was seen just to the outer side of the right ureter. I thought it was too small
to give rise to any symptoms, and so decided to crush the stone. It was
caught with the lithotrite, but when I commenced to crush it, it slipped out of
the jaws of the instrument, and I could not find it again. I then cystoscoped
the patient, and found the stone in the diverticulum. The bladder was opened,
and the stone removed from the sac, which was just large enough to hold it
comfortably. The orifice of the diverticulum was then enlarged downwards,
and the wound closed. What happened to the whole calculus in this case may
easily happen to fragments in others, and I feel sure this is one of the causes
of recurrence in these cases. Case V also bears out this point. The patient
underwent a suprapubic lithotomy, and two litholapaxies in the space of about
a year, yet when I operated there was a stone lying free in his bladder, and
the diverticulum was packed full of them. I feel strongly that the correct
procedure in all these cases is to open the bladder, remove the calculus, and
excise the diverticulum.

Section of Urology

(2) Stone in the Diverticulum .—In this case the indications for removing
the diverticulum are even stronger. Mere removal of the calculus may make
the patient’s condition worse, just as a simple cystotomy does. A very
interesting case illustrating this point has been described by Kummer and
Brutsch [5]. Their patient suffered from the usual symptoms of stone for
over twenty years. He never had retention, and there was only a small
quantity of residual urine. A stone was felt in his bladder, and the diagnosis
confirmed by radiography, which showed a shadow filling up the greater part
of the true pelvis. The bladder was opened, and two calculi were found lying
free in it, while a third was seen projecting from the orifice of a very large
diverticulum, which it filled completely. They were all removed, but the
diverticulum was left in situ . After the operation, the patient was absolutely
unable to pass urine naturally, and had to rely on self-catheterization. The
authors came to the conclusion that his retention was not due to atony of
the bladder, but to the presence of the diverticulum. They advised an
operation for its removal, but the patient refused it.

If possible, the diverticulum and the stone in it should be removed at the
same sitting, but if the patient’s condition will not stand this operation,
one must remove the stone first. In this case the diverticulum must be
drained independently, and the operation for its removal performed as soon
as possible after the lithotomy.

Relationship of the Ureter.

It is important for the operator to bear in mind the close relationship
between the ureter and the neck of the diverticulum. In the first place, the
orifices of the “ lateral group ” of diverticula are always found in a limited
oval area of the bladder wall, which lies above and to the outer side of
the corresponding ureteric orifice. Occasionally the ureter opens into the
diverticulum itself, in which case its orifice lies just within the lower and
internal quadrant of the mouth of the sac. Outside the bladder the relationship
is even more intimate. If the ureter is traced upwards from the point where
it enters the bladder wall, it will be found to lie at first immediately below the
lowest point of the neck of the sac. It then passes backwards and upwards
behind it. This means that it follows the curve of the lower and posterior
quadrant of the opening. If the ureter is traced still further upwards, it will
be found to lie either in the cleft between the bladder and diverticulum, or to
occupy a deep groove in the posterior wall of the latter. If the diverticulum
stands well away from the bladder, the ureter lies between the two, but if it is
in close contact with the bladder wall, and especially if it lies partly behind
the bladder, the ureter occupies a deep sulcus in its posterior wall. In either
case the ureter is compressed, or displaced by the drag of the sac; and
dilatation of its upper part, and of the corresponding renal pelvis, has frequently
been observed. In eight of my cases the ureter was exposed during operation,
and on each occasion it was found either to be dilated or thickened. If the
ureter opens into the diverticulum itself, it usually tunnels through the lower
and posterior quadrant of the neck. This is simply an exaggeration of the
usual relationship. The proximity of the ureter to the diverticular orifice
must be borne in mind whenever the condition is treated by splitting down the
partition between the sac and the bladder. Such an incision should not be
made directly towards the internal meatus, but should be curved forwards
a sufficient distance in order to avoid any chance of injury to the ureter.

68 Joly: The Operative Treatment of Vesical Diverticula

Residual Urine.

Perhaps one of the most remarkable phenomena connected with vesical
diverticula is the large amount of urinary obstruction they cause. In fact
obstruction and infection are the most usual indications for operation. The
amount of residual urine is usually measured by passing a catheter immediately
after the patient has emptied his bladder as completely as possible by
micturition, but in some cases, especially if the diverticulum is large, it is
impossible to drain off all the urine by this means. The amount left behind
is often considerable, and may for convenience be called the 44 concealed
residual.” I first suspected the presence of this concealed residual in Case II.
At the operation, the bladder was washed out, and emptied as completely as
possible, and then filled with air. Yet when it was opened the diverticulum
was full of lotion. The presence of this concealed residual was also demon¬
strated by means of the cystograms taken in Cases XII and XIII. In both
these cases, the first cystogram was taken when the bladder was filled to
repletion. It was then emptied as completely as possible by means of a
catheter, and the second exposure made. In both cases the diverticulum
remained full, and in addition there was a distinct shadow due to the presence
of a certain amount of opaque fluid in the bladder itself. Although it is easy
to demonstrate the presence of this concealed residual I do not know of any
means of accurately estimating its amount. This concealed residual is of great
practical importance, as it renders fallacious all attempts to estimate the
functional activity of the kidneys, by means of tests applied to the bladder
urine. This applies both to the elimination of dyes and to the urea concen¬
tration test, and if these methods are used the urine should be obtained
directly from the kidneys by means of ureteric catheterization. For example,
in Case XII, the urea concentration test carried out on bladder urine gave
only 1*4 per cent., while the same test carried out on urine obtained by
catheterization of both ureters gave 3 per cent, of urea from each kidney.
The latter was the true estimation of the renal function; in the first case the
urine was diluted with lotion which could not be evacuated from the bladder
by means of the catheter. If it is impossible to catheterize the ureters, one
must depend on an estimation of the blood urea.

Diagnosis.

In the majority of cases the diagnosis of the presence of a diverticulum is
made by means of the cystoscope. The appearance of the orifice of a large sac
is so characteristic that it is impossible not to recognize it at a glance.
Occasionally, however, cystoscopy is rendered difficult on account of intense
cystitis, or the orifice may be hidden by bullous oedema or a growth, or if the
bladder has not been fully distended it may lie between two folds of mucous
membrane. In these cases a cystogram should be made. The diagnosis of the
size and relationship of the diverticulum can be made by means of cystograms,
but to obtain the best results the technique must be carefully thought out. I
now use a solution of sodium iodide which has been boiled and allowed to cool
to the body temperature. The strength of the solution depends on the capacity
of the bladder, which should be estimated beforehand. If it is less than 10 oz.
I use a 15 per cent, solution, if it lies between 10 and 20 oz. a 10 per cent,
solution is best, while if the capacity is more than 20 oz. a 5 per cent, solution
is quite sufficient. If too strong a solution is used, the shadow is so dense that
it is difficult to distinguish between the shadow thrown by the diverticulum

Section of Urology

and that thrown by the bladder. In Case XII a 30 per cent, solution was
used, but the shadow was much too dense, and there was practically no
differentiation between the bladder and diverticulum. As a general rule, the
weakest opaque solution that will give a satisfactory shadow is the best one
to use. When the patient is on the X-ray couch, a catheter should be passed,
and the contents of the bladder evacuated as completely as possible. The
opaque solution should then be run in, either by means of a syringe or by
gravity, until the patient experiences a desire to micturate. A spigot is then
placed in the catheter, and a radiogram taken in the antero-posterior position.
The patient is then rolled over on his side, until the shadow of the diverticulum
is distinct from that of the bladder. The best position is easily determined
by means of the fluorescent screen. If the diverticular opening is in the
posterior part of the bladder, as it nearly always is, the patient should be
rolled to the opposite side. A second exposure should be made in this
position. Lastly, without altering the patient’s position, the spigot should be
removed from the catheter, and the bladder emptied as completely as possible.
A third exposure should then be made. This is to ascertain if there is any
“ concealed residual urine.”

Conclusions.

(1) Excision of the sac is the only rational treatment of vesical diverticula.

(2) No single set operation is suitable for all cases.

(3) If the case is complicated by prostatic or urethral obstruction, both
conditions should be treated at the same sitting. When this course is not
feasible, it is better to remove the diverticulum first, and treat the obstruction
at a later sitting.

(4) A preliminary cystotomy does more harm than good in most cases.

(5) The presence of a calculus either in the bladder or in the sac is an
indication for excision of the diverticulum.

(6) As a rule the ureter lies in close relationship with the neck of the sac,
and must be guarded from injury during operation.

(7) The contents of a diverticulum cannot always be evacuated by
catheterization. The urine left behind after catheterization, often a con¬
siderable amount, I have termed the “ concealed residual.”

(8) The presence of concealed residual urine vitiates all tests of the renal
efficiency which are carried out on bladder urine. To obtain an accurate
estimate of the renal function it is necessary either to catheterize the ureters,
or to trust to an estimation of the blood urea.

(9) The presence of a diverticulum is best diagnosed by means of the
cystoscope, and its size and position ascertained by means of cystograms.

REFERENCES.

[lj Joly, “Congenital Diverticula of the Bladder,” Proceedings of the Urological Section,
Seventeenth International Congress of Medicine, London, 1913. [2] Idem, loc. cit. [3] Marion,

“ De la resection des diverticules vSsicaux,” Joum. d'Urol., Paris, iv, p. 785 et seq. [4] Young,
“ Excision of Vesical Diverticula after Intravesical Invagination by Suction ; a New Method,”
Stirg., Gyn. and Obst., February, 1918, pp. 125-132. [6] Rummer and Brutsch, “Calculose

v^sicale geante, diverticulaire et libre. Etude de l’6tat fonctionnel des reins et de la vessie,”
Joum. d' Urol., Paris, xii, pp. 175 et seq.

Section of IHroloas.

President—Sir John Thomson-Walker, F.R.C.S.

The Incidence of Malignant Disease in the apparently Benign
Enlargement of the Prostate.

By R H. Jocelyn Swan, O.B.E., M.S.

I SHALL begin by making a clear definition of the point I wish to raise; it
is not my purpose to discuss those cases of prostatic enlargement which are
obviously carcinomatous or even suspicious of carcinoma when they first come
under the notice of the surgeon, but rather those cases which, clinically, present
all the features of the ordinary simple prostatic enlargement, and which are
operated upon as such, but in which, owing to some unusual feature in the
operation or upon subsequent microscopical examination of the organ removed,
malignant disease is found to be present as an unsuspected complication. Four
such cases have recently come under my observation, and I am therefore
bringing the subject forward in the hope that some points which may have
escaped me may be elucidated and assist us in arriving at a correct diagnosis
before operation is advised. Thus I eliminate at once those cases of alteration
in micturition, with difficulty, frequency and perhaps haematuria, which on
rectal examination present a firm, inelastic, or nodular swelling of the prostate,
with fixation or lateral infiltration in the pelvic lymphatic planes, and I confine
myself to those cases in which the digital examination of the prostate per rectum
shows a soft, elastic, movable enlargement of the gland of uniform consistence
which has been looked upon as the type of enlargement variously spoken
of as adenomatous, cystic adenoma, hyperplasia, or as chronic lobular
prostatitis.

Perhaps it would be best at this stage briefly to record the cases upon
which my remarks are based:—

Case I.—J. C., aged 75. Increasing frequency of micturition began about five
years ago; this progressed gradually until micturition took place every hour by day
and about five times at night, with occasional involuntary dribble. He has to
strain to micturate, but there is no pain, no backache, and no increased thirst. No
hamaturia.

On examination: Rather feeble. Pulse 76, vessels slightly thickened. Blood-
pressure 160 mm. Neither kidney nor liver palpable. The bladder not felt to be
distended. Urine passed in forceless dribble: clear, acid, specific gravity 1021; No
albumin nor sugar. Urea 2'3 per cent. Catheter passed easily; residual urine,
8 J oz. Per rectum : Prostate uniformly enlarged, smooth, elastic and movable. Easily
felt bimanually.

Au—U 1

[May 31, 1923.

72 Jocelyn Swan: Malignant Disease in Prostate

Operation, July 20, 1921: Prostate projected into bladder as a apple-like swelling,
smooth and elastic. Enucleation easy, though there was some increased fixation in
posterior part of gland. On subsequent examination with patient in the Trendelen¬
burg position and the cavity illuminated, two small firm nodules were found in the
posterior part of the prostatic cavity and were removed.

The prostate removed appeared to be of the ordinary fibro-adenomatous type,
but it was rather ragged on the posterior aspect. On microscopic examination of
this portion of the gland and also of the small nodules removed from the posterior part
of the cavity, adenocarcinoma was found to be present.

When seen again four months later, he looked well and passed urine comfortably
and with good stream. Frequency five times during day and once at night. A No. 14
steel sound passed easily, but there was a feeling of roughness upon its passing
through the prostatic area like rubbing against wet wash-leather. Per rectum the
prostatic area was found to be small, but there was a firm band of infiltration as thick
as the forefinger passing outwards and upwards on the right side, in the area of the
pelvic lymphatics. No glands felt.

The patient died on August 17, 1922, thirteen months after the operation, from
progressive weakness, but Dr. Hovenden wrote that at no time had he the slightest
difficulty in passing a full sized catheter. No post mortem was obtained.

Case II.—Major A., aged 61. Seen with Dr. Shackleton on December 1, 1922.
In December, 1919, he consulted his doctor owing to the occurrence of a blood-stained
emission ; he was then found to have an enlarged prostate, and upon catherization was
found to have residual urine. From this time there was increasing trouble in
micturition, hesitation, and frequent desire. In September, 1921, he had acute
retention, requiring catheterization. Frequency gradually increased to two-hourly day
and night, and a month ago his doctor found his urine very purulent and his bladder
considerably distended. He had no backache, but marked thirst and loss of appetite.
Had never seen blood in his urine.

On examination : Thin, with flushed cheeks. Arteries thickened; blood-pressure
170. Tongue dry and brownish. Urine passed turbid with pus, alkaline, specific
gravity 1004 and albumin present. Bladder remained distended to within 1 in. of the
umbilicus after micturition. Neither kidney was palpable. Per rectum : Prostate
found enlarged, flat, smooth, elastic, and readily movable. Blood urea, 72 mg. per
100 c.c.

On December 7, 1922, a Pezzer tube was passed into the bladder above the
pubes under local anaesthesia. On the following day the urea concentration test
only showed a percentage urea of 1*5 and 1*6 in the second and third hours.

On December 17 blood-urea had fallen to 38 mg. per 100 c.c. and urine-urea
was concentrated to 2 per cent, and 2*2 per cent, in the second and third hours.

Operation, December 19, 1922 : Prostatectomy. Enucleation easily carried out
except in the upper and posterior part, where the gland was adherent. Prostate gland
was of moderate size, showing many adenomatous, rounded masses, but was
lacerated on the posterior aspect. Dr. Fry reported that the glandular structure
showed irregular invasion of the surrounding tissue, with loss of basement membrane
and irregular mitoses, indicating adenocarcinoma.

Except for some trouble from haemorrhage on the fifth day, the patient did well, and
was healed and passing urine naturally on January 6, 1928. On February 14 he
looked well, and the tongue was clear and moist. A catheter was passed easily.
Per rectum the prostatic area was soft, but there was some thickening in the left
pelvic lateral space suggesting commencing infiltration of the lymphatic area.

Case III.—F. B., aged 62, had had trouble with frequent micturition and slow*
forceless stream for four years, gradually increasing until three weeks ago, when he
had acute retention, for which a catheter was passed. Again retention nine days ago,
and since then a catheter has been passed twice a day ; he only passes a few drops of
urine per urethram w r hen straining at stool. No haematuria; no backache nor
thirst.

Section of Urology

On examination: Thin, hard-working man. Arteries thickened. Tongue moist
and clean. Neither kidney nor liver felt. Bladder distended to 2 in. above pubes.
Catheter passed and 20 oz. of urine drawn off, hazy, acid, specific gravity 1016,
albumin present. Per rectum : prostate found enlarged, smooth, elastic, but firm; left
side larger than right. Prostate gland movable and could be felt bimanually.

Operation, June 28, 1921 : Left lobe of prostate very easily enucleated, but right
lobe somewhat adherent in lateral aspect. On subsequent examination this surface
found to be ragged, though the whole appeared to be the usual soft so-called adeno¬
matous enlargement. Microscopic examination by Dr. Eastes showed, however, active
adenocarcinoma, consisting of polyhedral cells arranged in primitive glandular form.

Patient did well after operation, and the wound closed in twenty days. During
convalescence a tube of radium was passed into the prostatic cavity and allowed to
remain in situ for four hours on alternate days, for six applications. Six months later
patient was passing urine with good force, but the frequency had increased to three-
hourly by day and twice at night. No straining. Urine clear and free from albumin.
Patient complained of aching in right sacro-iliac and right sciatic areas. Glands could
be felt to be enlarged in right iliac fossa above Poupart’s ligament, and on rectal
examination there was found to be a hard, nodular infiltration in the right lateral pelvic
lymphatic area. The patient lost weight rapidly, though he had no further
difficulty in micturition, and died in February, 1922, eight months after operation.

Case IV.—S. B., aged 78. Seen April 15, 1922. Had had increased frequency of
micturition for about five years, chiefly during day, with feeble, forceless stream. No
pain. On April 18 had acute retention, and his doctor could only pass a No. 6 catheter
with difficulty. The next day, the retention remaining, no catheter could be passed,
and he was in considerable pain from distension of the bladder, with overflow dribbling
of urine.

On examination his tongue was dry and glazed. He had bilateral backache
and marked thirst. The bladder was very distended and tense. Per rectum , the
prostate was found to be enlarged, soft, uniform in consistence and movable. Attempts
at catheterization failed, a stricture and false passage being present in the bulbous
urethra. A small tube was passed into the bladder above the pubes and the urine
slowly drained off. The urine was blood-stained, specific gravity 1012; it contained
albumin but no sugar.

Ten days later his tongue was moist and clean, thirst had gone, and the urine was
clear. The blood urea was 41 mg. per 100 c.c., but there was no previous test for
comparison.

Under an anaesthetic the stricture was divided and the suprapubic incision was
enlarged. The prostate was projecting into the bladder in bilateral form, and was easily
and rapidly enucleated. The gland showed the usual rounded fibro-adenomatous
masses, but it was noted that the right lobe was more dense than the left, and was
slightly reddened. Pathological examination by Dr. Eastes showed that there was
undoubted carcinoma present in a small area in the centre of the right lobe. The
patient made an excellent recovery from the operation, but died subsequently from
diabetic coma.

I would like to here mention another case (for the notes of which I am
indebted to my colleague Mr. Percival Cole), though I do not include it in my
series.

Case V.—J. C., aged 75. This patient was operated upon in 1917 for an apparently
simple prostatic enlargement; he had had prostatic symptoms for three years and for
three weeks previous to operation complete retention requiring catheterization. The
prostate was enlarged, smooth and elastic and was looked upon as adenomatous.
It was easily enucleated and the pathological report returned stated that it was
adenomatous, though it does not appear that any microscopic section was made.

In February, 1923, he was again admitted to hospital owing to difficulty in

74 Jocelyn Swan: Malignant Disease in Prostate

micturition. Frequency was increased to every half-hour during the day and to four
or five times at night with great straining. No catheter could be passed; upon each
attempted passage the catheter was arrested in the prostatic urethra. Under spinal
anaesthesia a filiform bougie was passed with difficulty and the firm tissue in the
prostatic area was incised with an internal urethrotomy knife. This was followed by
rigors and hyperpyrexia, sweating and death after nineteen hours. At the post mortem
the whole of the prostatic area was found to be occupied by firm, hard tissue which
proved on microscopic examination to be spheroidal-celled carcinoma. There was
glandular infiltration in the iliac and lumbar glands, but no evidence was found of
visceral metastases.

This case is very similar to the case reported by Mr. Thompson at the last
pathological meeting of this Section.

An analysis of the records of these cases shows that they present the usual
train of symptoms, spread over some years, of gradually increasing difficulty
and frequency of micturition associated with the ordinary benign prostatic
enlargement, and that clinical examination of the prostate by digital palpation
per rectum failed to convey any suspicion of malignant disease. It was only
at the operation for removal of the gland that any difference from the usual
simple enucleation was found, when subsequent microscopic examination
revealed the presence of carcinomatous infiltration in the area in which some
fixation of the gland to the surrounding “ capsule ” had occurred. In the
first three cases the operation was followed by carcinomatous infiltration
in the lateral pelvic lymphatic space which was certainly not present before it.
It is a noteworthy fact, however, that micturition could be performed freely
even when this recurrence was well established. In one case the enucleation
presented no difficulty from fixation, and subsequent microscopical examination
revealed a small central focus of malignant disease in one lateral lobe, this
finding being even a greater surprise than in the cases in which some capsular
adhesion had been found to have taken place. My opinion is that this
condition occurs more frequently than would be thought and it is an indication
that every gland removed at operation must be submitted to a close micro¬
scopical examination before it can be pronounced wholly innocent. In each
case the average length of history given by the patient before seeking advice
was about four years, so that the progress of each case cannot be looked upon
as any more rapid than the ordinary benign prostatic enlargement; neither
pain nor haematuria had been a feature in any of the cases.

I must confess that in many cases of prostatectomy, the macroscopic
appearance of the gland removed has not given rise to any suggestion of
malignancy, so that in a large number of my cases no critical pathological
examination has been made. Since, however, I have become aware of the
possibility of unsuspected malignant disease being present, I have had each
gland examined and I find that these four cases form four in a total of
twenty-eight consecutive prostatectomies, or roughly 14 per cent. Owing to
my failure to have the glands examined in all cases previous to this series,
figures from my former series of cases would not be reliable. I have, however,
enlisted the services of Dr. Eastes and Dr. Fletcher and have their permission
to make use of the following figures and I take this opportunity of thanking
them for their trouble in obtaining them for me. In a series of 678 prostates
removed by operation and submitted to them at the Laboratories of Pathology
and Public Health for pathological examination during the last ten years,
no less than 174 or 25*7 per cent, were definitely malignant, whilst they
classify 58 others, or 8*6 per cent., as border-line or precancerous; 443, or

Section of Urology

*65 3 per cent, were innocent (adenomatous), and three, or 0*4 per cent., were
tuberculous. Dr. Fletcher adds the following criticism of these figures :—

“ I think the findings, however, must be discounted to some extent by the fact that
many surgeons send for examination only those prostates about which they themselves
have doubt, and destroy the others. On the other hand, in the vast majority of these
prostates, only certain parts have been cut and not complete cross sections of both
lobes—in fact in many cases I only received a piece of the organ. This would militate
against the other factor, but I think not to the same extent and I consider that the
percentage of malignant prostates given by these figures is higher than it would be if
all prostates removed were examined. Those classified as precancerous are border-line
eases about which pathologists might well differ and I should think most are innocent.”

Table showing Result of Examination of Prostates.

Percentage

Definitely malignant

174

25*7

Borderline cases (precancerous)...

Innocent (adenoma)

443

65*3

Tuberculous

Total

678

0*4

These figures and Dr. Fletcher’s remarks upon them are very valuable,
representing as they do the microscopic findings in prostates removed by
operation in the practice of a large number of surgeons; but, as he justly
remarks, the incidence of carcinoma in 25‘7 per cent, is probably higher than
the true proportion. I think, however, that we may fairly assume that the
operation for the removal of the gland in the very great majority of these cases
was performed under the diagnosis of a simple enlargement of the organ,
though I know that I for one have not sent him many prostates that I have
removed because I thought the naked-eye appearance was conclusive that the
tumour was innocent—an error now rectified.

In 1914 Wade, of Edinburgh, found that in a series of 134 specimens of
enlarged prostates, fourteen were carcinomatous. 1 In ten out of these fourteen
•cases, the prostates were removed by operation and their condition was found
to be similar to that found in the cases I have described, that is, they were
removed under the assumption that they were affected with benign tumours and
were only found to be carcinomatous on subsequent microscopic examination.
Wade states that in these cases the carcinoma commenced in the centre of an
area of chronic lobular prostatitis (by which term he describes the common
adenomatous enlargement), and he remarks that in this fortunate circumstance
enucleation is at first easy. I would remark that in three out of four of my
oases the malignant disease appeared to commence in the periphery of the
gland and in only one in the centre. Wade further emphasizes the necessity
of obtaining complete sections of the whole gland before an opinion can be
expressed as to the existence of early carcinoma. His opinion is that the
malignant change occurs in a gland that has already undergone enlargement
by innocent “ hypertrophy.”

Wilson and McGrath, 11 in 1911, noted that carcinoma may be found in a
prostate removed by operation for apparent benign enlargement, and they
remark that the malignant focus appears to commence in an area of prostatic
enlargement.

i Ann. Surg ., 1914, lix, p. 331.

• Joum. Amer. Med. Assoc., 1911, lvii, pp. 1601-6.

Jocelyn Swan: Malignant Disease in Prostate

At the meeting of the International Urological Congress held in London in
1911, a long discussion took place on the “ Ultimate Result of Prostatectomy/’ 1
In the report of the various papers there submitted, I am unable to find any
definite record of the finding of carcinoma in the apparently benign enlargement.
Hugh Young, in a series of 450 cases upon which he operated, gives no record
of any found to be malignant, but quotes some cases in which, as the result of
operation, the urinary obstruction was not completely removed or else it
partially returned. In most of these cases there was improvement after
second operations, but in some there may have been unsuspected carcinoma.
Proust, Zuckerkandl, Thomson-Walker and Cuthbert Wallace, in their contri¬
butions to the same, discussion made no reference to malignant disease.
Fullerton, of Belfast, mentions two cases in which the firmness of the gland
on rectal palpation gave rise to a suspicion of malignant disease and in both
the microscopic examination proved this to be present, but neither could be
called cases of unsuspected carcinoma. Marion, Casper and Pasteau also
do not refer to it.

A serious note of the condition is brought out by our President
(Sir John Thomson-Walker) in an address on 4 Some Problems of Prosta¬
tectomy ” delivered before the Harveian Society in November, 1922. 2 In
discussing the advisability of operation in early cases, he gives as a reason
for this that malignant changes may occur in a prostate the seat of simple
benign enlargement. He states that it may occur at the periphery of one lobe
as a localized firm, inelastic area, which at operation strips with difficulty, or
that it may occur in the centre of a lobe that has shelled out readily at the
operation. In a series of 100 consecutive cases of prostatectomy for apparent
simple enlargement by Sir John Thomson-Walker, no less than sixteen were
found by the pathologist to show areas of carcinomatous change. In eleven of
these sixteen cases there was nothing in the clinical examination to suggest
malignancy in any form ; in four there was a small firm area on one side and
in one the prostate was somewhat firm in consistence. These figures are of
the utmost importance and if the combined figures reported by Wade, by
Sir John, and those above reported by myself, be added together it gives
a total of thirty-four cases of unsuspected carcinoma out of 262 cases in
prostates removed by operation for apparent benign enlargement in three
series of consecutive cases reported without selection—or a percentage rate of
nearly 13’0. This is a sufficiently large proportion to be borne in mind when
discussing with a patient the necessity for early operation and in outlining the
prognosis after operation in these cases.

In the course of the foregoing remarks, I have tried to refrain from any
discussion on the true pathology of the enlarged prostate and I only introduce
it at this stage in order to institute a certain analogy with the types of
carcinoma seen in other organs of the body. The senile enlargement of the
prostate has been termed by different pathologists 44 adenoma,” “ cystic
adenoma,” 44 simple hyperplasia,” 44 chronic lobular prostatitis ” and 44 inter¬
stitial prostatitis,” and as far as I can gather they have not yet made up their
minds as to which class it is to belong. The pathologists are not the only
persons in doubt about the prostate, for surgeons still seem to be divided in
their opinion as to whether the operation of prostatectomy is to be regarded
as a complete enucleation of the whole gland or as the removal of adenomatous

1 Ann. tics mal. des organcs gen. urin ., 1911, xxix (ii), pp. 2146, 2221.

2 Lancet , 1922, ii, p. 1121.

Section of Urology

masses from a false capsule formed of compressed prostatic tissue. I do
not venture to express any decided opinion on these vexed questions, which
might in turn, in these days of prostatic surgery, change other opinions forcibly
expressed in the earlier days; my motive this evening is rather to direct your
attention to the comparative frequency with which carcinoma may exist as
a small undetected focus in a prostate the seat of senile enlargement. The
analogy which I wish to point out is that between these cases and those of
carcinoma in other glandular structures in the body. In the case of the breast,
of the tongue, of the stomach and of the intestine, as well as in that of other
organs, the opinion has been expressed that carcinoma may occur in areas
which have been the seat of simple chronic inflammation or of ulceration.
May not the same sequence occur in the prostate and thus carcinoma commence
as a focus in a gland already the seat of the benign enlargement ?

DISCUSSION.

Dr. C. G. CUMSTON (Geneva) said that in his experience he had found the percentage
of malignant foci in apparently simple prostatic hypertrophies to be practically the
same as that arrived at by Mr. Swan. He (Dr. Cumston) had for many years taught
that the adenomatous prostate was in every way, clinically, closely similar to the
adenomatous breast in the female, a neoplastic process which, sooner or later, under¬
went malignant transformation, and this applied to adenoma of the prostate. These
central or peripheral malignant foci, while still small, were impossible to diagnose
clinically, and it was only by careful and complete histological sections of the gland
removed that they could be discovered. Text-books were misleading in stating that
cancer of the prostate could be diagnosed when the gland was large, hard and nodular.
When the morbid process had attained the nodular phase the growth would probably
have become inoperable or at least would have involved the periprostatic lymph nodes,
so that recurrence resulted in a very brief lapse of time following enucleation. Hence
every prostate removed should be submitted for histological study of the entire
gland.

Mr. Frank Kidd said that Mr. Jocelyn Swan had done well in bringing up this
matter for discussion. The moment was timely, as this kind of case was becoming
more common. Before the war he (Mr. Kidd) was accustomed to have sections cut
of the prostates removed from his hospital cases. Almost invariably the report came
back 4 ' fibro-myo-adenoma.” For that reason he had been inclined to discount the
figures given by Albarran and Young of the incidence of microscopic carcinoma
occurring in prostates removed as being simple, namely, 14 to 20 per cent. He
(Mr. Kidd) supposed that the incidence was higher in France and America than it was
in England. Since the war, and especially during the last two years, he had been
very much impressed with the increasing number of reports that came back on
prostates—which he had removed as cases of enlargement of a simple nature—labelled
“ precancerous ” or “ showing evidence of cancerous change in part of the gland."
This he had put down to the worry and under-feeding of the war as he believed that
worry was one of the most important predisposing causes of cancer. So much
impressed had he been with this pathological finding that for some time past he had
used it as an argument for early operation in the cases of patients coming to consult
him. Whereas previously in an early case one had been inclined to leave it to the
patient to decide on operation after the matter had been fairly put to him, now be felt
it to be his duty to impress the patient with the fact that an early operation might be
saving him from the onset of cancerous change in what appeared to be a simple prostate.
It was a very important additional argument in favour of early operation. He thought
there was now sufficient evidence to enable them to say that a so-called simple

Jocelyn Swan: Malignant Disease in Prostate

adenoma could in the course of years develop a focus of malignant change which would
eventually spread in the usual manner of an ordinary carcinoma of the prostate. He
based this evidence largely on the length of the history. The ordinary straightforward
carcinoma had usually a very short history, all the symptoms appeared within nine
months or a year, and they all came on more rapidly and more intensively than those
in simple enlargement of the prostate. Whereas in those cases Mr. Swan was discussing
there was very often a history of prostatic symptoms lasting over four or five or more
years. Again, some of these cases had been seen and examined years before and a
simple hypertrophy found, but years later the patients had turned up and had been
operated upon ; and then malignant change had been found in what had been taken
to be a simple gland. Was it possible for a surgeon to train himself to detect these
carcinomatous changes in a simple adenomatous prostate? If once this possibility
were borne in mind, he would, no doubt, become more expert. The point upon which
he (Mr. Kidd) would lay most stress was that these prostates were “ flat ” rather than
hard. For many years he had taught the importance of considering the “ flatness”
when palpating a prostate gland. “ Flatness ” was the best word to express what was
felt, as opposed to the rounded undulating projection presented by a simple prostate
on its rectal surface. Diagnosis was of the utmost importance because it was possible,
if one could make the diagnosis previous to operation, to carry out Young’s total
perineal prostatectomy rather than an ordinary suprapubic enucleation.

Only a few months ago he (Mr. Kidd) had made up his mind in dealing with what
was apparently a case of simple adenoma of the prostate that there was a small nodule
of growth buried in one of the lobes. For that reason he had advised Young’s total
prostatectomy and had carried it out successfully. Though the specimen appeared to
the naked eye to be adenomatous, yet on section he had been relieved to find that there
was definite evidence of early carcinomatous change. He had now done a fair number
of these operations for early carcinoma of the prostate and could recommend it as
giving most satisfactory results. It was surprising to find how little shock there was
in carrying out this operation and how well the patients behaved during their con¬
valescence. Young’s operation deserved a wider trial in this country.

On the other hand, if it was not possible to make a diagnosis of carcinoma before
operating, and if one had enucleated such a gland and had found that the microscopic
report was “ carcinoma,” there was still much that could be done. The question had
been asked: “After all was there anything to be done when this discovery was made ? ”
Personally he (Mr. Kidd) always advised these patients to submit to some form of
radio-therapy. In his opinion the best results could be obtained by giving the patients
an exposure with the Erlangen X-rays, though other forms of radio-therapy might be
tried. Was it reasonable to suppose that after the main mass of cancer had been
removed by operation, radio-therapy would be able to deal with the small amount of
cancer cells left behind in the tissues ? At any rate it seemed more reasonable to
expect it to do this than to expect it to destroy the whole mass of a cancer not
submitted to a previous operation.

Another point that needed the greatest care in considering the diagnosis of the nature
of a prostatic enlargement was that of paying close attention to the posterior portion of
the base of the prostate and to the portion of tissues just above that which lay between
the vesicles. These were the spots at which carcinoma was most likely either to start
or to spread, though it could arise in other portions of the gland. The point was well
established that prostates removed at operation should be carefully cut and examined
by a pathologist. Nevertheless in his experience it was not always possible to base
the prognosis on the pathological report. Some cases reported as malignant did w T ell,
and never gave any further trouble, whereas other cases reported as non-malignant
developed metastases in a few months, particularly in the bones, and the result was
disappointing. He recalled three cases operated upon in the same month in 1919, of
w hich the following were brief records :—

Case I.—In this case he had been uncertain whether he was dealing with a fibrous, malignant,
or simple prostate. Enucleation proved extremely difficult, and he felt certain that malignant

Section of Urology

disease was present, yet the pathologist reported “ chronic fibrous prostatitis, certainly no
evidence of malignant disease.” Six months later that patient had developed a single secondary
deposit at the top of the vertebral column and his head fell forward and he aied in a moment.

Case II.—The patient’s prostate had been adenomatous for some years. It was removed
without the slightest suspicion that it was malignant. On cutting it through after the operation
he (Mr. Kidd) had noted certain areas that looked to him a little suspicious. Sections confirmed
the suspected malignancy of these areas, yet they had been completely encapsulated in large areas
of simple adenoma and it would certainly have been thought that all malignant tissue had
been removed. In three months this patient had developed large bony deposits of malignant
disease and he died within six months.

Case III.—Here the patient had a prostate that was obviously malignant on one side, yet for
certain reasons it was thought advisable to attempt enucleation rather than undertake Young’s
perineal operation. Enucleation was carried out satisfactorily, and ever since that time the patient
had had no difficulty whatever in passing water. Nevertheless, from time to time he developed
large malignant nodules in the bones ot his spine and in the ribs and even in the lungs; he
became very ill for some weeks, and was almost at death’s door, then he suddenly recovered and
all the deposits disappeared.

He recorded those cases in order to show how impossible it was to state a certain
prognosis in any given case. If an attempt was made to set a time limit the only
certainty was that one would be wrong. In this connexion it was important to
remember the extraordinary latency of carcinoma. For instance, he (Mr. Kidd) re¬
called a case in which Sir Frederick Treves had simply removed the breast and had left
the pectoral muscles in 1895 for proved carcinoma of the breast. The patient had
remained quite well until 1912, then she developed secondary deposits in the axillary
glands on the same side. He (Mr. Kidd) had carried out a complete Sampson-
Handley operation as if the breast were still present. The glands had proved to
be malignant, and the deposits must have been there seventeen years. The patient
had since remained perfectly well for another eleven years.

The following principles, therefore, should be accepted in dealing with carcinoma:
(1) In many cases cancer cells lay latent in the tissues for many years, and only lighted
up under stress of worry, over-work and exhaustion. (2) Spontaneous healing of
secondary malignant deposits did occur, and was perhaps not so uncommon as was
often thought. For instance, he had opened a man's abdomen and had found
extensive malignant disease of the stomach and peritoneum. Sections were cut.
Within four months all signs of trouble had disappeared, and the man had remained
perfectly well.

He would relate one very curious case that bore on the diagnosis of malignant
prostate :—

Mr. Hurry Fenwick had cystoscoped a patient and could see what appeared to be a malignant
ulcer about the size of a half-crown lying near the base of the bladder. Mr. Fenwick sent the
patient to the London Hospital with a request to him (Mr. Kidd) to carry out permanent drainage.
Upon his opening the bladder he found the ulcer exactly as described and it was lying on the top
of the left lobe of the prostate. The edges did not feel thickened or malignant and he could
distinctly feel there was a large adenomatous prostate present. He therefore enucleated the
prostate, the specimen carrying out the ulcer with it. The ulcer proved to be a simple one and
the prostate a simple one. It was therefore possible for a simple prostate to ulcerate into the
bladder, though he considered this a rare phenomenon.

Mr. E. T. C. MILLIGAN said that two cases of the condition the subject of Mr.
Jocelyn Swan's paper had recently come under his care. In one the prostate at the
time of enucleation had been found to be adherent at one part to the capsule. Re¬
currence of growth was rapid, and a sound was only passed with great difficulty into the
bladder on the twelfth day after operation. Post-operative obstruction continued. The
man was fitted with a permanent suprapubic drainage appliance, and only lived a few
months. This was a contrast to the cases recorded that night, some of which had lived
for years. The prognosis after operation was difficult, and there was an analogy in
cancer of the rectum in which the same difficulty arose: a small recent growth easily,
and apparently completely, removed, recurring with great rapidity, whereas clinically
unfavourable growths sometimes did not recur for years. From the point of view of

80 Jocelyn Swan: Malignant Disease in Prostate

prognosis, there were these two definite classes, but there was no recognizable pathological
or clinical feature by which to assign a given growth to the rapid or slow recurring
class. In his second case the growth of the prostate had been found on removal to be
adherent to the urethra, so much so that 1 in. of the urethra was removed with the
prostate, and it was this adherence that aroused the suspicion of malignancy, although
clinically the signs were those of a benign enlargement.

Section of Wroloas.

President—Sir John Thomson-Walker, F.R.C.S.

Two Points in connexion with Chronic Nephritis.

By Charles Greene Cumston, M.D.

(Geneva , Switzerland.)

The two points in connexion with advanced cases of chronic nephritis to
which I desire to call your attention are: (1) The total absence of albuminuria
in a fair percentage of these cases; (2) the value of Ambard’s constant for
ascertaining the real condition of the functional activity of the renal paren¬
chyma, and indirectly, the extent of pathological change present in the
kidneys.

In non-azotaemic patients one frequently meets with a permanent increase
of the constant and, as Ambard has shown, nephritides presenting a functional
renal inferiority of 80 per cent, may occasionally remain unrecognized.
Although the constant may not give any indication as to the exact duration
of the renal morbid process, it is at least an excellent index as far as the
intensity of the nephritis is concerned.

Ambard’s comparative tables reveal the fact that a constant of 0'07
corresponds to normal renal functioning, while a constant of 0 08 indicates
a 24 per cent, loss of renal activity, a constant of 0*09 to 40 per cent.; 0*10
to 51 percent.*; 0*11 to60 per cent.; 0*12 to 66 per cent. ; 0*13 to70 per cent.,
and 0*14 to 75 per cent.

_ Ur _

A/ D. 70. C
p. 5

Formula of Ambard’s Constant.
= K = Constant = 0'06 — 0 08.

Ur = Blood urea per 1,000 c.c.

D = Twenty-four-hour total of urea in the urine.

C = Urea concentration in urine in grammes per 1,000 c.c.

p = Body-weight of patient, calculated according to an average weight of 70 kgr.

In the cases studied—fifteen in all—the constant was estimated several
times at intervals of a week or ten days, in order to avoid erroneous conclusions
arising from a possible acute outburst of the chronic renal process, with the
result that the constant was invariably found above normal, varying from 0*09
to 0*12.

In conjunction with the estimate of the constant the phenol-sulphone-
phthalein test was used. I am not, however, averse to the methylene blue
test and resort to it frequently,
s—u l

[Jane 28, 1923.

82 Cranston : Two Points in connexion with Chronic Nephritis

The following brief outline of two case histories will serve to illustrate the
object of this short note:—

Case I.—Patient, aged 56. Prostatic hypertrophy. Nothing worthy of note in the
pathological antecedents until five years before coming under observation he began to
suffer from constant severe headache. During the past eighteen months has had
occasional attacks of vertigo, also cramps in the calves of the legs and some nausea.
Slight exertion dyspnoea. Somnolence after meals.

Examination: Fairly corpulent man with very ruddy complexion. Liver small,
spleen can be percussed. Heart and lungs normal. Blood-pressure (Pachon), Mx 20,
Mn 10. Polyuria, 1,700 c.c. to 2,100 c.c. No sugar, no albumin by fractional analysis
of urine. Very rare granular casts. Urea of blood: 0*57 gr., K 0*11. Phthalein test,
43 per cent. Since the loss of functional activity of the renal parenchyma was thus
estimated at 60 per cent, the patient was regarded as a bad operative risk and prostat¬
ectomy was refused. The patient died eleven months later from uraemia.

Case II.—Patient, aged 62. Prostatic hypertrophy. Early in 1918 had a slight
ictus lasting three days, followed by paresis of right arm. At this time and ever since
has had some exertion dyspnoea, occasionally nocturnal as well. Constant tinnitus.
Congestion of the face and occasionally some painful palpitations.

Examination, November 3, 1920: No paralysis. Pulse very hard at 86. Blood-
pressure (Pachon), Mx 21, Mn 11. Clanging second aortic sound. Lungs normal.
Polyuria, 2,000 c.c. to 3,000 c.c. No sugar, no albumin by fractional analysis. No
casts, Blood urea, 0’54 gr.; K 10*099. Phthalein test, 34 per cent.

The loss of functional activity being thus estimated at about 49 per cent., prosta¬
tectomy was done several weeks later after medical treatment, which reduced the
blood-pressure and polyuria and increased the phthalein elimination to 52 per cent. In
normal subjects the elimination varies between 56 per cent, and 68 per cent, in one
hour and ten minutes, hence in this patient the operative risk was not too great.
Recovery slow, but without untoward complications.

In practice it is not uncommon to encounter certain types of patients whose
clinical history offers very different symptoms, but symptoms which one should
be able, after a careful clinical study of the case, to attribute to their true cause,
namely, chronic nephritis. These subjects usually are more or less plethoric
and look in perfect health.

At times these patients complain of headache, which is increased by the
recumbent position and is uninfluenced by the use of sedatives. At other
times visual or auditory disturbances are marked, and very frequently attacks
of vertigo of the M6ni&re type occur. The phenomenon of the numb finger is
common—an important minor symptom—likewise occasional paroxysms of
painful palpitations. But what is particularly striking is the high blood-
pressure, the Mx sometimes attaining 20 to 22, Mn remaining normal or
nearly so, and this should call our attention to the kidney.

Fairly frequently there is some polyuria and pollakiuria, but repeated
analyses of the twenty-four-hour urine or fractional analysis will fail to reveal
the slightest trace of albumin. Dieulafoy maintained that albuminuria is not
a constant symptom of chronic uraemigenous nephritides, and Weill, out of a
total of 124 cases of azotaemia, found albumin absent in ten, otherwise 8 per cent,
of the cases.

Other clinicians have made the same remark. For example, Dr. Thomas
D. Lister in his book, “ Medical Examination for Life Insurance,” Ixmdon, 1921,
p. 61, says that “a history of nephritis, even if the urine be found free from
albumin, may have left after-effects. A high blood-pressure or a hypertrophied
heart may be found/’ This statement is sound, but, unfortunately, it would

Section of Urology

appear that Dr. Lister relies on Esbaoh’s picric-citric acid test for detecting
albumin. Unquestionably, this test is excellent for routine work, but it will
not reveal minute traces of albumin, hence it should be discarded where
absolute precision is required.

And again, where exactitude in the measurement of the blood-pressure is
essential, I would say that in my opinion, there are only two really reliable
instruments on the market, namely, Pachon's and Vaquez’s sphygmometers.
An instrument giving only the Mx pressure is valueless, as the true condition
of the blood-pressure can only be determined by both the Mx and Mn. One
should always specify which of the instruments has been employed for taking
the pressure. Whereas Vaquez’s and Pachon’s sphygmometers each give the
normal Mn, varying between 7 and 10, the normal Mx of Vaquez is 13, that
of Pachon, 17.

My opinion is that analysis of the total twenty-four-hour urine often may
be misleading and that small amounts of albumin voided at some time during
the day may be undetected; therefore, fractional analysis has been carried out
in all my cases in order to be able to affirm that no trace of albumin was at
any time present. It is a well known fact that during the evolution of chronic
uraemigenous nephritis an intermittent albuminuria may develop from various
causes—cyclical, digestive or orthostatic albuminurias—so that its presence
should be searched for by the fractional method, as follows:—

The patient is given two meals, one at noon, the second at 7 p.m. consist-
of a mixed diet. The patient voids his urine at 7 a.m., and this urine is
thrown away. Five sterile glass jars are used for collecting the twenty-four-
hour urine. The first collects the urine voided from 7 a.m. to noon; the
second from noon to 4 p.m.; the third from 4 p.m. to 7 p.m.; the fourth from
7 p.m. to 10 p.m., while the fifth collects from 10 p.m. to 7 a.m. inclusive.

By this fractional analysis we have found that very frequently chronic
uraemigenous nephritides evolute without ever presenting the slightest trace
of albumin, and that the number of cases of this clinical type is much higher
than is generally suspected. I look upon this as a most important notion,
because the absence of albumin should not lead one to eliminate the diagnosis
of a renal lesion, especially at the onset of the evolution of nephritis—a phase
during which the symptoms presented by the patient give no distinct clue to
the diagnosis, because this phase being that of compensation, does not give
rise to any pathognomonic sign.

The examination is completed by estimating the percentage of urea in the
blood, and the phenol-sulphone-phthalein elimination. A comparison of these
three diagnostic procedures will enable us to affirm that the case is one of
chronic uraemigenous nephritis—perhaps very advanced—evoluting without
albuminuria. ft * X 01 IP x 1 o

In surgical work many patients give no history of any serious medical
affection. They have always been well, and no serious disease or chronic
infectious process will be found in their antecedents. The classical analysis
of the urine is made and no trace of albumin found, with the result that the
functional activity of the kidneys is assumed to be intact,
i No one more than the surgeon has need of detecting latent uraemia, a
condition that can only be discovered by estimating the percentage of urea in
the blood, the use of Ambard’s ureo-secretory constant and the time elimina¬
tion of phthalein or methylene blue. If these tests be carried out the most
serious surgical catastrophes can be avoided.

In conclusion, I would say that it is essential to submit all surgical cases

84 Kidd: Candle removed from the Bladder of a Male

to thorough clinical examination when the patient's condition does not require
urgent interference; and that the absence of albumin from the urine is no proof
of renal integrity.

BIBLIOGRAPHY.

[1] A. Weill, Thesis, Paris, 1912. [2] Pasteur Vallery-Radot, Thesis, Paris, 1917.

[3] Ambard, “Physiologic normale et pathologique des Reins,” Paris, 1921. [4] Rathery,

“ Etude comparative des lesions histologiques du rein et de son examen fonctionnel,” Archives des
Maladies des Reins , i, No. 3, January 16, 1923.

Candle removed from the Bladder of a Male.

Specimen shown by Frank Kidd, M.Ch.

PATIENT, a male, aged 21, of foreign extraction, was brought to me on
June 2, 1923, with a story that for the last three months he had noticed
greatly increased frequency of micturition, accompanied by severe pain and
haematuria. He had been cystoscoped in a provincial town, and told he had a
growth which must be cut without a moment’s delay. He came up to town
to take a further opinion before deciding on such a serious step.

On examination I found that his urine contained a large quantity of pus.
A catheter was passed and the bladder washed clear, but it would only hold
4 oz. of lotion. On inspecting the interior of the bladder with the cystoscope
I could see a stone of moderate size lying on the floor of the bladder and
evidence of a moderate cystitis. There was no sign of growth or tuberculosis.
I took an X-ray picture, which I exhibit. This displays the stone, the centre
of which is translucent and surrounded by an outer ring of opaque substance.
I expressed the opinion that the shadow was a very peculiar one and advised
litholapaxy, which was performed on June 5. On catching the stone I found
that it crumbled in a very curious manner, which puzzled me, and I experienced
unusual difficulty in sucking the fragments out of the bladder. Finally I got
the bladder empty of fragments and confirmed this by cystoscopic examination.
Upon my examining the fragments I noticed that they consisted largely of a
wax-like substance looking like candle grease and that there was only a small
quantity of chalky or gritty matter, which consisted of calcium phosphate.

The next day I challenged the patient and asked him to account for the
presence of candle grease in his bladder. He then informed me that he placed
it there on the advice of a friend and had since not told anyone about it.
He had suffered from frequent nocturnal emissions. His friend told him that
an unfailing cure was to melt candle grease, work it up into a rod shape and
insert it into the urethra. The result was not so happy as he had confidently
expected.

When he was last heard of his cystitis had cleared up and he felt quite
well again.

Section of Urology

86 -

Pyelogram illustrating the Breaking of Two Shadows into
Multiple Shadows as the Result of Injection of Sodium
Bromide.

By W. Girling Ball, F.R.C.S.

J. H., female, aged 26, post office clerk, was admitted to St. Bartholomew's
Hospital on April 30, 1923, with a history of dragging pain in the left loin,
which had been persistently present for nine months. She had not had any
attacks of renal colic or other symptoms relative to the urinary tract. The
only other symptom was an increase in the pain after vigorous exercise,
usually relieved by resting.

The girl was healthy in appearance and presented no obvious physical signs
to account for her symptoms. The urine was natural. She pointed to tho
left lumbar region as the site of her pain. The X-ray appearance demonstrated
the presence of two shadows which I thought might be tuberculous glands.

A pyelography was then carried out, which demonstrated that the renal
pelvis was situated in the site of these shadows and that there was a degree of
hydronephrosis, as the pelvis held some 30 c.c. of sodium bromide. The'
interest of the investigation, however, lies in the fact that a picture taken
the next day showed that the two shadows had been broken up, demonstrating
that calculi were present. A hydronephrotic kidney with eighteen small stones-
composed of a mixture of calcium oxalate, calcium phosphate, ammonium
magnesium phosphate and uric acid were found.

Case of Malignant Growth of the Renal Pelvis, with Calculi.

By Sir John Thomson-Walker, F.R.C.S.

J. N., MALE, aged 63. Examined May 19, 1915. Had suffered from renal
colic as a young man and a swelling had been noticed in the right side.
Twelve years ago he fractured his femur and since that time the attacks of
renal colic had ceased. For some years there had been slight attacks and
three months ago a severe attack of hcematuria. For three weeks he had been
passing gravel with a recurrence of the pain. If he lies on the left there ia
dragging pain in the right side. There had been some loss of weight.

On examination there was found to be dragging pain in the right loin.
There was increased frequency of micturition to two hours during the day and
once or twice at night. A large mass was found in the right flank, bulging
laterally and obliterating the waist line. From the main mass a rounded mass
projected anteriorly and about reached the level of the umbilicus. The main
mass was dull on percussion and the second mass had a half-tympanitic note.

An X-ray examination showed two rounded opacities in the right flank and
a smaller opacity at a lower level. The right kidney shadow was increased in
size but the outline was indefinite.

Cystostoscopy showed a copious efflux of dark blood from the right ureter.

The urine drawn from the right ureter had the following characters:
Acid, 1022 ; semi-solid on boiling; urea, 1*25 per cent., contained red blood
corpuscles fresh and as “ shells ” ; a large amount of granular blood pigment;
a considerable number of pus cells ; casts of red blood corpuscles and of blood

86 Thomson-Walker: Malignant Growth of the Renal Pelvis

pigment and a few epithelial casts ; large masses of both small and large
epithelial cells; mucous oxalate crystals.

Urine of left kidney : Acid, 1030, contained a small amount of blood ;
urea, 2*05 per cent. Microscopically there were red blood corpuscles, blood
pigment, tailed cells and small round epithelial cells ; a few cellular casts and
granular casts ; no crystals.

Operation, June 9, 1915: Right kidney exposed and found to be a very
large thin-walled hydronephrosis containing several pints of dark blood-stained
fluid. On removing the sac it came away easily at first but there were dense

Calculi and malignant growth of the renal pelvis.

adhesions to the colon along the front- The lower pole and posterior surface
were also densely adherent. On attempting to expose the ureter it was found
to be surrounded by a dense hard nodular mass which lay at the inner and
lower aspects of the kidney. The vascular pedicle was exposed and tied from
above and the kidney and dense hard mass were dissected away from above
downwards.

Convalescence was rapid and uninterrupted. In October, however, his
temperature began to be raised. On October 16, a little indefinite resistance

Section of Urology

could be felt in the right loin. Ten days later a mass the size of a fist could
be felt, and this rapidly increased and he lost weight. He died on November 4.

The specimen {see figure) shows a large multilocular hydronephrosis of the
renal type with two stones the size of date seeds in the narrow lumen of the
pelvis. The wall of the renal pelvis is replaced by a large irregular dense mass
of tissue. On microscopical examination this shows the histological structure
of a carcinoma. The cells are very degenerate for the most part and are
irregular in shape. They are arranged in small groups in a fibrous stroma.

Case of Vesico-urethral Calculus.

By Sir John Thomson-Walker, F.R.C.S.

C. C., aged 33, railway porter; admitted February 2, 1923 ; discharged
February 28, 1923. Complaint: Pain in peritoneum and tip of penis at
beginning of micturition.

History: Passed a small stone when aged 7. Since then has occasionally
passed gravel, and had scalding pain in the urethra during micturition.
No serious trouble until Chrismas, 1922, when he had considerable difficulty
in micturition ; much delay, straining and frequent interruptions; relieved by
medicine. One week later had retention for six hours relieved by catheter.
This was the first instrumentation and the only time any blood was passed.
Since Christmas, frequency : day, two hourly ; night, once or twice ;
urgency; occasionally incontinence if he delays to relieve himself; pain in
perineum and penis.

Condition on admission : Act of micturition : delay, strainmg, poor
projection, good stream, interrupted; instruments obstructed in prostatic
urethra. Bladder: not distended. Perineum: tender, no stone felt. Rectal
examination: stony hard mass felt, size of cherry, just above prostatic
urethra ; very tender on palpation. Urine : turbid with threads, alkaline, 1020,
no albumin or sugar. Microscopically, pus cells and phosphates seen. Daily
urea: 1*4 per cent, in 49 oz. 295 gr.

X-ray report: Dumb-bell shaped opacity in pelvic view suggestive of
vesical calculus with a prolongation downwards into the prostatic urethra.

Operation, February 5, 1923: General anaesthetic ; Trendelenburg position ;
suprapubic lithotomy; mushroom-shaped calculus easily removed with fingers.
Bladder mucosa and prostatic urethra remarkably healthy; i-in. tube into
bladder, small prevesical drain. Uneventful convalescence.

PROCEEDINGS

OF THE

ROYAL SOCIETY OP MEDICINE

EDITED BY

Sir JOHN Y. W. MacALISTER

UNDER THE. DIRECTION OF

THE EDITORIAL COMMITTEE

VOLUME THE SIXTEENTH

SESSION 19*2:2-23

WAR SECTION

LONDON

LONGMANS, GREEN k CO., PATERNOSTER ROW

1923

IHIiar Section

OFFICERS FOE THE SESSION 1922-23.

President —

Lieut.-General Sir John Goodwin, K.C.B., C.M.G., D.S.O., A.M.S.

Vice-Presidents —

Major-General Sir Alfred P. Blenkinsop, K.C.B., C.M.G., A.M.S.
Surgeon-Captain R. S. Bond, R.N.

Air-Commodore David Munro, C.I.E., R.A.F.M.S.

Hon. Secretaries —

Surgeon-Commander G. O. M. Dickenson, R.N.
Lieut.-Col. C. R. Sylvester-Bradley, R.A.M.C.
Squadron-Leader B. A. PLAYNE, D.S.O., R.A.F.

Other Members of Council —

Surgeon-Commander SHELDON Francis DUDLEY, R.N.
Colonel Sir Matthew H. G. Fell, K.C.B., C.M.G., R.A.M.C.
Colonel Percy Evans, C.B., C.M.G., A.M.S.

Colonel Claude Buist Martin, C.B., C.M.G., A.M.S.
Wing-Commander MARTIN WILLIAM FLACK, C.B.E., R.A.F.

Representative on Library Committee —
Colonel J. Crawford Kennedy, R.A.M.C.

Representative on Editorial Committee —
Colonel J. Crawford Kennedy, R.A.M.C.

WAR SECTION

CONTENTS.

March 13 , 1922 .

Squadron Leader H. E. Whittingham, M.B., D.P.H., D.T.M., R.A.F., M.S. pagk

Observations on Sand-fly Fever in Malta ... ... ... ... 1

November 13 , 1922 .

Surgeon Rear-Admiral William Bktt, M.V.O., R.N.

Venereal Disease as a War Casualty ... ... ... ... ... 15

„ „ „ . ... (Corrigendum) 44

December n, 1922 .

Colonel R. 0. Camphkll, D.S.O.

Physical Training in the Army ... ... ... ... ... fll

April 9 , 1923 .

Squadron-Leader T. S. Rippon, R.A.F. Medical Service.

The Efleet of Tropical Climate on Physical and Mental Efficiency ... 45

The Society does not hold itself in any way responsible for the statements made or
the views put forward in the various papers.

London :

John Bale, Sons and Danieisson, Ltd.,

Oxford House,

83-91, Great Titchfield Street, Oxford Street, W. 1.

Mai* Section.

President—Sir John Goodwin, K.C.B., C.M.G., D.S.O., A.M.S.

Observations on Sand-fly Fever in Malta.

By Squadron Leader H. E. Whittingham, M.B., D.P.H.,

R.A.F., M.S.

In the spring of 1921 the D.M.S. of the Royal Air Force decided to appoint
a Commission to investigate the causation, prevention and treatment of sand¬
fly fever. This measure was considered necessary owing to the high sickness-
rate from that disease which occurred during the previous year amongst the
R.A.F. personnel in the Middle East. Malta was chosen as the best locality
in which to carry out these investigations ; the chief reasons being its isolation,
freedom from malaria, and the relatively small chance of encountering epidemic
jaundice, relapsing fever, and other tropical fevers—compared with such a
country as Mesopotamia.

A fever having a fairly definite clinical picture, and commonly called 44 sand¬
fly fever/’ has been known to affect British forces serving in the Mediter¬
ranean since the year 1799 [1] [2]. Not only is the fever of a fairly definite
type, but the date of the onset of cases of the fever can be predicted yearly with
reasonable accuracy [l] [2] [3] [4] [5] [6]. Still the diagnosis of this fever
is far from a simple matter. This may be gathered from a perusal of the
excellent summary of the “ total continued fevers ” of the Mediterranean made
by Birt. In his survey of the historical evidence of these fevers he is able to
divide most of the cases into the following groups : (l) Typhoid, (2) Malta
fever, (3) simple continued fever. The latter heading accounts for most of
those milder cases termed 44 sand-fly fever.” It was obvious in the past, before
this subdivision of the fevers in Malta, that there was more than one type of
fever, but it is hardly to be expected that all mild cases of fever are of neces¬
sity true cases of sand-fly fever. Nor are all so-called cases of sand-fly fever
simple in their nature [1] [2] [3]. Thus the Army Medical Report of 1823
[7] , dealing with Malta [7], states that the symptoms of summer fever (sand¬
fly fever) during the early part of summer were chiefly severe frontal head¬
aches. Later in the year liver symptoms, resembling yellow fever, were not
infrequent. There were three deaths out of 304 cases. Again Marston [8]
refers to the varying types of fever with different years, the period of fever
varying from three to five or seven days. Relapses occurred in 15 per cent,
of the cases. Whereas the Army Medical Report, 1897, divides 44 Mediter¬
ranean or simple continued fever” into two distinct types: (l) With two to
three days fever, ending by rapid recovery, (2) with seven to ten days fever,
ending by gradual recovery, a glance at Table I will convince the most casual

N—W 1 [March 18, 1922.

2 Whittingham: Observations on Sand-fly Fever in Malta

observer that the continued fevers of the so-called tropics are very
numerous. The differential diagnosis of such fevers must take into
consideration the following diseases:—

Table I.— Commoner Continued Fevers occurring in the Tropics.

(1) PHLEBOTOMUS OR SANDFLY

FEVER.

(2) INFLUENZA.

(8) DENGUE OR BREAK-BONE FEVER.

(4) Seven day or Saku fever.

(6) Rat-bite fever.

(6) Yellow fever.

(7) Japanese river fever.

(8) Spotted fever of the Rocky Mountains.

(9) Typhus, Brill’s disease or Tarbardilla.

(10) WEIL’S DISEASE OR EPIDEMIC

JAUNDICE.

(11) Trench fever.

(12) Relapsing fevers.

(13) MALTA FEVER.

(14) Malaria.

(15) PNEUMONIA.

(16) SEPSIS.

(17) Trypanosomiasis.

(18) EtfTERICA.

The fevers indicated by capitals are those likely to be encountered in Malta.

The work thus resolved itself into :—

(A) A preliminary investigation to determine areas in which sand-fly fever
was most prevalent.

(B) A direct investigation comprising (1) methods of differential diagnosis :
(2) attempts to isolate the causal virus ; (3) breeding and lethal experiments
on the sand-fly ( Phlebotomus papatasii).

(A) The preliminary investigation to determine the areas in which sand-fly
fever was prevalent was adopted early in the year as a tentative measure prior
to sanction being obtained to investigate the disease in a sand-fly fever district.
The only method applicable when most of the work had to be performed in this
country was to arrange for the collection of a blood smear from every case of
pyrexia occurring overseas. By this means and by the clinical data supplied
it was hoped to arrive roughly at the percentage of errors in diagnosis. More¬
over, there was the possibility of detecting sand-fly fever and sand-fly-fever-free
areas. This latter information would aid materially in the choice of a ground
for future research.

(B) The direct investigation was carried out at the R.A.F. Station, Cala-
frana, Malta. A nominal roll of the personnel at that station was prepared,
showing the term of service out of England, the nature of any previous fever,
and the date of T.A.B. inoculation. From this roll it was easy to isolate
all those who had not spent a summer overseas before. These men were
inspected and had their temperature taken daily. Any who had fever were
immediately admitted to the sick quarters. Those with a temperature of
99° F. were instructed to report at the laboratory a few hours later to have
their temperature again recorded. In this way cases of fever were diagnosed
in their early stage.

(I) Methods of Differential Diagnosis.

Every case admitted to the sick quarters was carefully examined, and only
those showing typical symptoms of sand-fly fever were accepted for the
investigation. In all, twenty-six cases of apparent sand-fly fever were investi¬
gated. To aid in the differential diagnosis all the cases were subjected to a
definite routine.

(1) Blood cultures were made as soon as possible after admission on
the first day of fever in every case. The blood was disposed of as follows :—

2 c.c. were inoculated into 1 c.c. of Wenyon-Noguchi medium
5 c.c. were inoculated into 30 c.c. of Wenyon-Noguchi medium
5 c.c. were inoculated into 30 c.c. of nutrient broth

3 to 5 c.c. were inoculated into guinea-pigs intraperitoneallv in fifteen cases

War Section

(2) Agglutination tests were performed with Garrow's agglutinometer on
the first and tenth day of disease against Bacillus typhosits , Bacillus para-
typhosus A and B, Bacillus enteritidis (Gaertner), Bacillus dysenteries (Shiga
and Flexner), Micrococcus melitensis and para-melitensis . It was necessary to
test the blood serum for agglutinins on these two days in order to interpret
correctly the effects of preventive T.A.B. inoculation.

(3) Wassermann tests were collected on the first and tenth day of disease to
ascertain whether syphilis was present or not, or whether sand-fly fever had
any effect on complement deviation.

(4) Blood Counts .—As the degree of anaemia is only slight in sand-fly fever,
the estimation of the red blood corpuscles and the percentage of haemoglobin in
the peripheral blood was not adopted as a routine measure. Daily total and
differential leucocyte counts were done on twenty-six cases over a period
varying from eight to fourteen days. In two cases hourly leucocyte counts
were performed for twenty-four hours in order to ascertain the onset of the
leucopenia stated to occur in this disease. Four normal control bloods were
examined daily.

Technique .—The daily counts were collected at the same hour of the day
(9 a.m.), with the same instruments, and by the same observer in each case.
The blood was collected from the lobe of the ear. The lobe was rubbed with
cotton wool to stimulate the circulation and then punctured with a sharp
needle. The first drop of blood was wiped away and then the specimens were
collected. The total white counts were mounted three times and the leuco¬
cytes on the 400 squares of a Thoma-Zeiss haemacytometer slide counted with
each mounting. An average of the three mountings was accepted as the correct
total white count. The smears for differential counts were stained by Leish-
man’s method and a count of 400 cells made in every case; 100 cells were
counted along one edge, 200 by zig-zagging through the central portion of the
smear and 100 at the other edge of the film. The temperature (oral) of the
patient was taken while the blood was being collected. This routine eliminated
as far as possible errors of technique.

(5) Urine examination was carried out daily on all the cases. Special
search was made for albumin, bile and spirochsetes.

(6) A thorough clinical examination was made and particular attention paid
to ( a ) the accurate recording of temperatures ; ( b) the conjunctive for jaundice
and congestion, the skin for bites, rashes and ulceration ; (c) spleen and liver
for size and tenderness; (d) the lymphatic glands for enlargement or
tenderness ; (e) the naso-pharynx or air passages for inflammation.

(II) Attempts to Isolate the Causal Virus.

From previous work done by Birt and others [3] [9] it was proved that
the blood of man was infective by direct transmission to other men only on the
first day of disease. Thus it was decided to limit the blood culture work to
the first day of disease.

The isolation of the causal virus was attempted in two ways: (1) By direct
blood culture in Wenyon-Nogucbi medium; (2) by in tra peritonea l inoculation of
guinea-pigs with blood from sand-fly fever cases.

(l) Direct Blood Culture. —As previously stated, blood was intubated into
nutrient broth in order to ascertain the presence or not of such organisms as
those of the enteric group, Micrococcus melitensis and Streptococcus; into
Wenyon’s modification of the special spirochete medium advocated by Noguchi,
by which means it was hoped to detect organisms of this nature if present.

N—W hi

4 Whittingham: Observations on Sand-fly Fever in Malta

Aerobic and anaerobic cultures were prepared. The broth cultures were
incubated at 37° C., the Wenyon-Noguchi cultures at 27° C. The successful
cultivation of spirochaetes depends to a large extent on the medium employed.
The composition and preparation of the Wenyon-Noguchi medium [10] was
as detailed below : A 0 2 per cent, fluid agar was very accurately neutralized
to 7*6 Ph.; 15 to 20 drops of sterile rabbit blood were added to this shortly
before the medium was required for use.

The formula for the medium was as follows:—

Agar-agar ...
Sodium chloride
Peptone
Lemco

Distilled water to

2 per cent.
0‘5 per cent.
1 per cent.
0*2 per cent.
100 c.c.

or 20 grai.
or 6 grm.
or 10 grm.
or 2 grm.
or 1,000 c.c,

Great care had to be exercSsed in the neutralization of the agar. This was
attained by the hydrogen-ion method [11].

Neutralization with Cresol Red .—Five c.c. of the melted agar was taken.
This was diluted with 20 c.c. of hot doubly-distilled water. A few drops of
0*02 per cent, cresol red was added, NaOH was gradually added from a
burette until the first purplish tinge was obtained. This occurred with a
hydrogen-ion concentration of Ph. 7*5.

Further Neutralization tvith Phenol Red .—The medium was then neutral¬
ized with NaOH almost up to the point recorded by the cresol-red method
and tested with phenol red. The determination of the end point with this
latter reagent was more complicated.

The apparatus necessary included the following: (1) Set of standard Ph.
solutions with indicator added to show Ph. reaction from 6, 6*2, 6*4, 6*6, 6*8,
7*0, 7*2, 7*4, 7*6, 7*8, 8*0, 8*2 ; (2) a comparator to hold the tubes for com¬
parison ; (3) special cordite tubes (Coles* tubes); (4) phenol-red solution
0*01 per cent.

One c.c. of the hot melted agar was added to 4 c.c. of hot distilled water in one
of the cordite tubes and 0*5 c.c. of a 0*01 percent, solution of phenol red added.
The tube was put in the comparator in the slot between the standard tubes
representing Ph. 7*4 and 7*6 respectively. In order to render the reading more
accurate two other cordite tubes were partly filled with the agar diluted 1 to
4, and one placed behind each of the standard tubes. Behind the tube of
media under test to which the phenol red was added was placed a cordite
tube containing distilled water. The colours were compared, and then the
tube under test was cooled beneath the cold water tap until its contents were
at room temperature, and the comparator again used. If the amount of alkali
added was not sufficient a little more was added, and after the medium was
thoroughly shaken the reaction again tested.

The stock agar was kept thus : The agar for use was diluted 1 in 10
with 0*85 per cent. NaCl and, before the rabbit’s blood was added, it was
again tested with phenol red to determine the hydrogen-ion concentration.
The correct reaction being thus established the medium was run into test
tubes, 10 c.c. to each tube, or else 30 c.c. into 2 oz. bottles.

The addition of the rabbit's blood was accomplished in batches of fifteen
to twenty tubes as required. The method adopted was that of Wenyon.
A rabbit was placed in a special box so that the ears could be freely manipulated
without the animal moving. One ear was cleaned up and the hairs cut and
shaved off a good area at the outer margin. (Whiskers of that side of the
animal were also cut as the blood dropping from the ear to the test tube would

War Section

be liable to contamination from this source.) The shaven area was then
treated with 4 per cent, iodine in spirit. Thereafter, molten paraffin wax was
applied with a sterile glass rod. This application was carefully made to the
edge and under surface of the ear. Several layers of melted paraffin were
applied. In order to make the marginal vein prominent the ear was clipped
near its root with a pair of bull-dog forceps. A sharp sterile needle was
inserted into the vein and immediately the blood welled out. As the drops
fell they were collected into the tubes of 0*2 per cent, agar heated to 50° C. ;
fifteen drops were collected into each 10 c.c. of agar. This amouht gave
a distinct fibrin network. At one sitting it was usual to add the necessary
amount of blood to fifteen to twenty tubes without ill-effects to the animal.
The same rabbit was used again after intervals of three weeks.

(2) Inoculation of Guinea-pigs with Whole Blood .—Three to 5 c.c. of
citrated whole blood from fifteen cases of sand-fly fever were inoculated intra-
peritoneally into guinea-pigs. These pigs had their rectal temperatures taken
morning and evening for three days before inoculation in order to ascertain
their normal temperature. Control pigs were inoculated with a similar quantity
of sand-fly fever-free blood.

(Ill) Breeding and Lethal Experiments on the Sand-fly

(Phlebotomies papatasii ).

These have been devised and will be carried out in Malta this summer.

Results.

(i) Differential Diagnosis.

(1) Blood cultures sown in broth as a routine measure proved sterile in
every case.

(2) Agglutination tests were negative in all cases, due allowance being made
for the protective inoculation with T.A.B. vaccine.

(3) Wassermann test was negative in every case chosen.

(4) Blood Counts .—The total leucocyte count showed in practically all the
cases a leucopenia (4,000 per cubic millimetre) for the first three to five days
of disease, followed by a leucocvtosis shooting up to 15,000 to 20,000 per cubic
millimetre on or about the ninth to eleventh day of disease. This was typical
of most cases (eighteen, i.e., 69 per cent.), but a few did not follow this
rule (eight, i.e., 31 per cent.). In order to arrive at a fair conception of the
leucocyte count as it occurs in sand-fly fever the daily total leucocyte counts
of the twenty-six cases were averaged with the result depicted in Chart I (p. 8).
The lowest average count was on the first day of disease (5,400 per cubic
millimetre) ; after three days the count became normal and remained so for
four days ; thereafter a moderate degree of leucocytosis occurred—the count
swinging up to 13,600 per cubic millimetre on the tenth day of disease. This
leucocytosis was only transitory and disappeared in the course of two to three
days. Hourly total leucocyte counts (two cases) showed that the count was
normal at the onset of disease, but as the temperature rose the count fell,
reaching its lowest point six to nine hours after the onset of disease. Later as
the temperature fell the count again rose to normal limits.

The lowest count recorded in this series of cases was 2,700 per cubic
millimetre on the first day of disease, the highest 20,600 per cubic millimetre
on the tenth day of disease.

6 Whittingham: Observations on Sand-fly Fever in Malta

The differential leucocyte count showed that in the first six days of the
disease the large mononuclear lymphocytes were relatively increased, registering
between 12 and 25 per cent. The leucopenia chiefly affected the polymorpho¬
nuclear leucocytes. In some cases the small mononuclear lymphocytes were
increased above 30 percent., but this did not occur until after the tenth day of
disease. Broadly speaking all through the disease for fourteen days there was
a total lymphocytosis of 40 to 50 per cent. Many of the cases showed a
relative polymorphonuclear increase on the first day of disease, and from the
figures obtained from hourly counts it was seen that a lymphocytosis was
established after a few hours. As regards the eosinophils these tended to
disappear during the fever, but returned to normal after the sixth day.
In dengue there was stated to be a late eosinophilia, so special attention
was paid to this point [14] [15] [16]. The figures obtained were:—

Eosinophils over 3 per cent, in nine cases (33 per cent, of the cases examined)
Eosinophils over 4 per cent, in five cases (20 per cent, of the cases examined)

Eosinophils over 5 per cent, in three cases (11 per cent, of the cases examined)

There was only a true eosinophilia in 11 per cent, of the cases. This eosino¬
philia occurred on or about the sixth to ninth day and passed off within three
days in all except one case. This latter case gave the highest eosinophil
count (9 per cent.).

The differential count showed very little change day by day; even when
the total leucocyte count rose sharply, as stated, about the tenth day, there
was no alteration, except that any eosinophil increase became normal at
that time.

The daily total leucocyte count, supported by a differential leucocyte count,
helped in establishing the cases as examples of the disease recognized as sand¬
fly fever by other authorities.

The leucopenia accompanied by a lymphocytosis has been noted by many
observers in the past. As early as 1816, Dr. Skey [12] remarked on the
absence of the buffy-coat from the blood of sand-fly fever cases. Only one case
out of twenty-eight showed the buffy-coat. McCarrison, in 1906 [13], and
Birt, in 1910, dealt with the subject more fully. Birt states that “ there does
not seem to be any great fluctuation in the number of the leucocytes from day
to day. The leucopenia may continue into convalescence. The polymorph
leucocytes are diminished ; they number about 56 per cent, instead of the usual
65 to 75 per cent. The large and medium-sized mononuclears are increased ;
the lymphocytes and eosinophiles are decreased.” Later in 1913 114], the
same observer refers to a late eosinophilia both in dengue and sand-fly fever.

The recent observations made in Malta confirmed these points as a whole,
except that there was found to be a marked daily fluctuation about the tenth
day; the leucopenia passed off in every case before the sixth day, and only in
three cases was there an eosinophilia which passed off in about three days.

Of the long list of diseases that might be confused with sand-fly fever
those which show a leucopenia during the febrile period are : (a) Dengue,
(I)) influenza, ( c ) seven-day fever, ( d ) enterica, (e) malaria.

Dengue shows a leucopenia associated with a lymphocytosis during the
fever. Balfour [15] and Harnett [16] refer to a late eosinophilia. This may
be due to the occurrence of dengue in areas where helminthic infection is
common. Generally speaking the eosinophils disappear from the peripheral
blood during any fever, so that in a person with a helminthic infection a return
of the eosinophils is likely after the pyrexia has subsided.

War Section

In a typical case of influenza a chart of the daily total leucocyte count
and temperature appears identical with that of a typical case of sand-fly
fever [17] (cp. in Chart I). As in sand-fly fever, there is a transitory eosino-
philia about the sixth to ninth day, but a point of distinction is that the
leucopenia in influenza is associated with a small mononuclear increase (see
Tables II and III).

Table II.—Leucocyte Count in a Typical Case of Sand-fly. Fever.

In 1,000's

Differential count per cent.

Per cent.

; £ .

—

1 1

I |

Temperatu
degrees F

4»

1-
— *3

aS O

Small

mphocyte*

CD >* !

28 |
oe js

; «

ac S*

i i

E i

Hyalines

*5 i

' 1 ;

i ce !

1 * 1

2 i

i f

1 1

x. !

O 1

•

3 !

Granular

>»

i e !

! * i

W |

; 998

1 076

. 0*6

2*3

172

144

1 122 i

1 534

| 100

4*7

, 1*03

i 0*5

2*8

! 124

124

—

98*4

1 05

| 0*5

1*6

; 142

434

—

5 |

982

| 0*8

0*9

1*3

202 1

1 23

i 162 j

324 i

6 1

98*2

6*8

1-3

! 0*9

2*4

194 1

144

25 1

364

—

7 |

1*2

0*9

204

16 ,

104

51 I

—

8*2

| 1-3

3*8

18*

17 !

152 '

462

—

976

1 1-6

0*6

204

7 ,

i 8 ,

60 1

—

986

188

| 2*2

! 1*6

12*9

7 '

682

11 1

8*8

1*3

| 0*4

5*4

154

54 1

144

612 '

10-2

! 21

| 1*6

4*6

214

152

454 ,

—

18 i

! 98 4

7 2

1 20

; 0-6

3*3

284

; 13 i

984

i 10

3*7

352

122

482

Note the Large Lymphocyte column (*) and compare the double figures in this column
in sand-fly fever with the single figures in Influenza (Table III).

Table III.— Leucocyte Count in a Typical Case of Influenza.

Day of disease j

Temperature
degrees F.

In 1,000's

Differential count per cent.

Per cent.

Total white
cells

■r.

X ft

Large

lymphocytes

Neutrophils

Small

lymphocytes

>»

Hyalines

Transitionals

*5.

tx>

Granular

102*6

7*5

1*2

0*3

4-8 •

1028

5*6

0*3

3*6

—

100

10*0

4*0

0*5

4*4

84 ;

—

100*2

10*6

3*0

0*9

5 6

fi'i

ha :

—

5*0

2*2

0*4

1*6

' 44

3*2

99*2

8*1

1*8

5*1

—

97*6

150

' 4*4

0*7

8’2

4 i

—

98*5

8*7

2*8

0*4

4*6

, 5

—

10*6

3*3

5*4

' 8

—

10*6

3*3

6*2

1 3A

1 4

—

6*5

1*7

0*3

3*5

! 6

! 41

97*2

16*2

5 9

0*5

7*6

1 :J i

—

7*5

1 2*5

0*2

1 14

—

97*2

6*8

2*9

0*2

3*1

' 24

—

16 i

97*4

23*7

6*3

1 1*0

: 12*8

1 46

—

16 I

26*8

6*2

1*4

146

i ^

11 ,

—

17 1

97*2

31*2 |

| 4*8

2*2

17*2

' •

1 i

—

* See also Large Lymphocyte column in Table II.

8 Whittingham: Observations on Sand-fly Fever in Malta

Enteric fever usually shows a normal count to begin with, later there is
a leucopenia associated with a lymphocytosis (large or small) [18]. Blood
culture and agglutination tests should decide the diagnosis here.

In benign tertian malaria the total leucocyte count is slightly increased
(10,000 odd per cubic millimetre) just before the occurrence of the fever;
as the temperature rises a leucopenia sets in (3,000 per cubic millimetre) but a
differential leucocyte count shows the hyalines increased to over 4 per cent.
Moreover, the malarial parasite can usually be detected. A daily count, taken
at 10 a.m. on a case of benign tertian malaria shows a count of 10,000 or more
white corpuscles per cubic millimetre on the day of fever and on alternate
days following this, and a relative leucopenia on the day of apyrexia; this
alternate daily rise and fall of the leucocyte count is very helpful in making
a diagnosis of malaria when parasites cannot be found.

A glance at a chart of trench fever shows an entirely different picture.
Here the temperature and total leucocyte counts run parallel. The fever is
associated with a definite leucocytosis (15,000 to 20,000 per cubic millimetre)

Chart I.—Graph showing the Temperature and Leucocyte Curves in Influenza,
Trench Fever and Sand-fly Fever.

Lcueoeytti
p *r cmm.

Influenza.

Trench fever

Sand-flv fever.

-- Daily temperatures.

..... Daily total white blood cell count.

. =. Normal temperature and white count.

Note —the leucopenia in the febrile state of influenza and sand-fly fever, whilst in trench fever
the fever is accompanied by a leucocytosis.

which persists for four to five days and recurs regularly for several weeks,
perhaps months. Moreover, the polymorph leucocytes are increased in this
disease (see Chart I).

(5) Urine Examination .—The urine of two cases showed a small amount of
albumin ; one of them also contained bile in a relapse on the eleventh day
of the disease. No spirochaetes were found in the urine.

(6) Clinical Examination .—In most cases the symptoms were typical—
the temperature in practically every case reached its highest limits on the first
day of disease—on an average 102° F. ; fell to normal within three days and

War Section

remained normal. Five cases (20 per cent.) showed a recrudescence between
the ninth and twelfth days of disease—the temperature was over 99° F.;
in fact, three of them had temperatures over 102° F. and all the symptoms of
an acute sand-fly fever attack. One showed jaundice with this recrudescence.
The latter case developed fever again on the twenty-fifth day after the primary
disease had appeared—hence this case was included amongst those of true
relapse. Three cases (12 per cent.) relapsed on the twenty-fifth, twenty-sixth
and forty-sixth days respectively after the first sign of fever. It will be noted
that leptospira were recovered from the blood of six cases—two of w r hich cases
showed relapse, and one a recrudescence of the fever.

Marston in 1855-6, in Malta [8], observed that relapses occurred in about
15 per cent, of cases at indefinite periods. Birt, 1910 [3], reports second
attacks in 6 per cent., and once or twice a recrudescence of the fever on the
fourth or fifth day. In the “ Memoranda on Medical Diseases in the Tropical
and Sub-Tropical War Areas, 1919 ” [20], an after-rise of temperature is said
to be by no means uncommon in some outbreaks.

From a consideration of such points as have been described the cases that
were chosen for this investigation conform to the diagnosis of “ sand-fly
fever/’

(ii) Attempts to Isolate the Carnal Virus.

(l) Direct Blood Culture. —Dark-ground illumination of the primary blood
culture from twenty-six cases in the Wenyon-Noguchi medium revealed after
the fifth to sixth day of incubation at 27° C.,the presence of spirocheetal bodies
in six cases. These spirochaetes morphologically resembled leptospira. Three
of these primary cultures were successfully subcultured. Unfortunately one
of the subcultures was contaminated, and lost in transit from Malta to
England.

The leptospira isolated were morphologically indistinguishable from Lepto¬
spira icterohaemorrhagix , the average length being 10 to 15 /*, and width about
0*3 p. They were very actively motile, proceeding in either direction at will.
A marked vibratory movement, like a piece of string being twisted and
quickly pulled taut, was very common. The organism crawled backwards
and forwards through any fibrin masses encountered, like a worm entering
or leaving the soil — a distinct elastic-like movement. Some forms had a
hook at one end, others at both ends, and others a hook shaped like a
“ ?-mark.”

As these organisms were found in cultures treated aerobically, in the latter
cultures the procedure of pouring sterile paraffin oil on the upper surface of
the medium was dispensed with. The organism was most abundant about f
to 1 in. below the surface of the medium. In fact after about ten to fourteen
days in some cultures a fine but distinct white haze formed a ring about an
inch from the surface of the medium ; this ring consisted of masses of
leptospira.

Secondary organisms, so common in the dust-laden air of Malta, quickly
killed off the leptospira in any cultures to w T hich they gained access.

One primary culture was maintained alive for fourteen weeks, a secondary
culture for nineteen weeks; after that it was lost through contamination.

For a time the organism grew readily in subculture, but recently after
seven months, difficulty has been found in recovering it from subcultures. The
technique has remained constant, and the media were very carefully
neutralized. As the organism could not be recovered from guinea-pigs at

10 Whittingham: Observations on Sand-fly Fever in Malta

any time, the method of animal passage to increase its viability could not
be utilized.

It is interesting to note that Couvy, 1921 [21], has reported from Beirut
the finding of spirochsetes in the blood of cases of dengue.

(2) Inoculation of Gtiinea-pigs with Whole Blood. —Most of the guinea-pigs
inoculated with the whole blood of sand-fly fever cases showed a rise of
temperature of about 2° F. for the first forty-eight hours after inoculation.
Control pigs inoculated with blood from presumably sand-fly-fever-free cases
failed to show this rise. Two of the control pigs collapsed and died in the first
twenty-four hours after the inoculation. There was an epidemic of diarrhoea
amongst the pigs—only a small number were really healthy before experi¬
mentation. Great difficulty was experienced in getting healthy pigs. All the
pigs that died were examined, cultures were made of their heart blood, liver
and kidneys, and the latter organs sectioned. In no case were leptospirae
found. None of the pigs developed any symptoms of epidemic jaundice.

As has already been stated, the blood from fifteen cases only was inoculated
into guinea-pigs. Owing to it being impossible to tell which cases would be
likely to yield leptospirae the cases chosen were taken at random. Thus two
of the cases from which leptospirae were obtained by direct blood culture
failed to have their blood inoculated into guinea-pigs; one of these cases later
developed jaundice. Fortunately four of the cases which gave a positive
blood culture were controlled by animal inoculation. These all proved
negative.

The cases which showed leptospirae in the primary cultures were the
following:—

(1) Case 17 (W.).—Sharp typical attack of sand-fly fever, June 30, 1921. Two-day
type of fever. Maximum temperature 102° F., registered on the first day of fever.
Recrudescence on twelfth day—another typical attack of sand-fly fever, maximum
temperature 102*2° F. ; returned to normal in forty-eight hours. Thereafter made good
recovery. Culture brought to United Kingdom ( see Chart II).

(2) Case 2 (J.).—Admitted July 2, 1921, with typical attack of three-day fever.
Maximum temperature 102*2° F. on the first day. Slight amount of albumin in the
urine on third and fourth days of disease. Temperature rose to 99° F. on twelfth day.
Leucopenia for first three days; lowest count 3,400 per cubic millimetre; marked
leucocytosis (20,600 per cubic millimetre) on tenth day. Felt weak for some time,
otherwise made an uninterrupted recovery. Culture brought to United Kingdom.

(8) Case 14 (M.).—Admitted July 8, 1921. Severe attack of three-day type of
fever. Highest temperature 102*8° F. on first day of disease. No leucopenia.
Leucocytosis (12,000 to 18,000 per cubic millimetre) after the third day. Felt very weak
after first attack. Relapsed on twenty-sixth day of disease ; temperature 108° F.:
three-day fever. Weakness followed. Culture contaminated in transit from Malta
to England.

(4) Case 5 (I).).—Admitted July 2, 1921. Mild attack of three-day fever.
Maximum temperature 100*6° F. on second day, and 99° F. on twelfth day.
Leucopenia for seven days; distinct leucocytosis on tenth day (18,000 per cubic
millimetre). Uninterrupted recovery. Primary culture contaminated in Malta.

(5) Case 15 (G.).—Severe case of four-day type of fever. Admitted July 8,
1921. Maximum temperature 103*6° F. on first day. No relapse. Leucocyte
count normal until fifth day, when there was a leucopenia (4,500 per cubic milli¬
metre) ; it rose on tenth day to 16,000 per cubic millimetre. Patient remained weak
for some time. Primary culture contaminated in Malta.

(6) Case 21 (P.). — Acute attack of three-day fever started June 29, 1921.
Maximum temperature 103° F. Recrudescence on eleventh day; temperature 102° F.

War Section

Jaundice developed after three days, disappeared in six days. Relapsed twenty-five
days after primary fever; temperature 102’4° F.; three-day fever with all the
symptoms of sand-fly fever. Primary cultures contaminated in Malta.

Chart II.

Table IV.— History of Sand-fly Fever as it occurred in the Six Cases from which
Leptospir.e were isolated by Direct Blood Culture.

Case i
No.

Typo of
fever

Recrudescence

Relapse

Blood inoculated
into guinea-pig

17 (W.) i

Two-da v

Twelfth day (102-2 F.)

Yes

2 (J.) ;

Three.dav

Twelfth day (99° F )

—

Yes

14 (M.) I

Three-day

i —

Twenty-sixth day (108° F.)

Yes

15 (G.)

Four-day

'! -

—

Yes

21 (P.) :

Three-day

Eleventh day 102° F. ,
jaundice fourteenth day

Twenty-fifth day (102-4 F.)

5( D.)

Three-day

1 Twelfth day (99° F.)

Experiments with Leptospira Isolated.

(a) Inoculation of Guinea-pi(js with Cultures of LejJtospinr.

As it was thought that the primary cultures might contain toxins as well
as the leptospira, they were not used for inoculation experiments on animals
or man. Three guinea-pigs were inoculated intraperitoneally with primary
subcultures—seven, eight and ten days old respectively. None of these pigs
died or showed any symptoms of jaundice or haemorrhage. Six guinea-pigs
were inoculated w ? ith one-week-old secondary subcultures. One of these pigs

12 Whittingham: Observations on Sand-fly Fever in Malta

died on the tenth day after inoculation. There was neither fever nor any
symptoms of note. Attempts to isolate leptospira from the heart blood, liver
and kidneys failed. Six guinea-pigs were inoculated with four weeks’ old
primary subcultures. One of these pigs died on the twelfth day after inoculation
without symptoms of fever, haemorrhage or jaundice, nor could leptospirae be
recovered from its blood or organs.

(b) Inoculation of Man with Cultures of Leptospira.

Only three men have been inoculated up to date—two in an area where
sand-fly fever occurs, and one in a sand-fly-fever-free area. Case 1 was
inoculated with i c.c. of primary subculture (six days old), Case 2 was inocu¬
lated with i c.c. of primary subculture (six days old), Case 3 was inoculated
with 1 c.c. of primary subculture (six weeks old), and nine days later a further
inoculation of 1 c.c. of a six-day old secondary subculture was carried out.

In none of the cases was there very definite fever. Case No. 1 had a
temperature of 99° F. or over, from the sixth to the eighth, after inoculation.
The highest point registered was 99’8° F. There was pain in the legs and
suffusion of the conjunctive for several days in Cases Nos. 1 and 2. Case No. 3
developed headache, anorexia, marked nausea, tendency to syncope, and pains
in the calves on the seventh to ninth days after the first inoculation. The
blood picture showed a distinct leucocytosis (15,000 per cubic millimetre).
A similar result, with more pronounced symptoms, lasting for several days,
followed the second inoculation.

On account of jaundice developing on the eleventh day of disease in one
of the sand-fly fever cases under investigation in Malta it was considered
inadvisable to do further inoculations in man.

Conclusions.

A disease clinically resembling sand-fly fever was studied in Malta.
Owing to the small number of cases investigated the following conclusions
must be accepted tentatively :—

(1) The type of fever was chiefly of the three-day type. In 20 per cent, of
the cases a recrudescence occurred between the ninth and twelfth days. In
12 per cent, of the cases relapses took place between the twenty-fifth and
forty-sixth days.

(2) The leucocyte count aided materially in the diagnosis of the disease and
it was established that a typical case of sand-fly fever showed an initial slight
leucocytosis which passed off in a few hours. A leucopenia soon set in and
persisted for three to four days. On or about the tenth day a distinct leuco¬
cytosis occurred; this was transient. The large lymphocytes were increased
during the first six days of the disease. There was no abnormal eosinophilia in
uncomplicated cases. The return of the lymphocytes to the normal number
was not completed in a fortnight. A third of the cases (thirty-one per cent.)
did not conform to this, but registered a more or less normal total leucocyte
count or a leucocytosis accompanied by a certain degree of polymorph increase.

(3) A leptospira , morphologically resembling the Leptospira icteroharmor-
rhagiw , was isolated on the first day of fever by direct culture from the
blood of six clinically sand-fly-fever cases.

Koch’s postulates have not been fully carried out in respect of this
organism ; it was isolated from the human blood stream and cultivated outside
the body; but inoculation into men and animals failed to reproduce the

War Section

typical disease, nor could the organism be recovered from the animals
inoculated. This failure may partly be due to the fact that the organism
must pass some part of its life cycle in another host (the Phlebotomies
papatasii) before it becomes properly infective.

The leptospira differed from the Leptospira ictcrohaemorrhagiae from its
not being pathogenic to guinea-pigs. It has .been found, however, that the
pathogenicity of cultivated spirochaetes may be quickly lost. Griffith [22]
states: “A culture grown at 37° C. which, when a fortnight old produced
typical spirochffitosis in a guinea-pig, lost its virulence within the next
fortnight. In another experiment with spirochaetes grown at 25° C., a
fourteen days’ old primary culture produced fatal haemorrhagic jaundice, while
the same culture when three and a half and four months old was completely
non-pathogenic.” Moreover, spirochaetes have been isolated from cases of
jaundice in France and Albania, which are non-pathogenic to guinea-pigs.

The point to consider is, were all the cases investigated at Malta true cases
of sand-fly fever ? The varying types of fever met with in Malta from year to
year and even during different stages of the hot weather have been commented
on by many authorities, including very old residents [l], [2], [3]. There
have been outbreaks of sand-fly fever varying from mild influenza-like attacks
to severe forms termed “ yellow fever.” In fact, yellow fever was reported in
Malta in the autumn of 1822, while the fever during the summer was of a
milder type. Dr. Lightbody remarked on the absence of the buffy coat
(i.e., leucopenia) during the summer, and its presence (i.e., leucocytosis) in the
autumn epidemic. Some of the cases investigated in the summer of 1921
showed a slight leucocytosis, some relapsed, one even developed jaundice.
It is just possible that the spirochaete found was a modified form of that which
causes epidemic jaundice—modified by passage and perhaps atmospheric
conditions. The latter point is suggested by the experiments carried out by
the R.A.M.C., at Millbank, in 1909 [3], with phlebotomi infected in Malta
from cases of sand-fly fever; there was no definite fever though abdominal and
syncopal symptoms were present.

Sand-fly fever is thought by many to be a disease scarcely worth considering.
The fever i3 soon over and the patient back to work. But outbreaks vary.
Convalescence may be prolonged for weeks and weeks. The nervous system
may be involved and such symptoms as weariness, mental depression, and even
insanity follow. D.A.H. may occur leading to syncopal attacks. These nervous
phenomena are serious enough on terra firma , but they are magnified considerably
in the case of the air pilot. A little delay in the reaction time may mean a serious
crash. In short a condition of “ flying exhaustion ” or “ neurasthenia ” is
produced. This may be due to any continuous strain on the nervous system,
whether it arises from physical or chemical causes. The toxins of sand-fly
fever come into the latter category.

It is obvious that sand-fly fever is a serious menace to the man-power
of the R.A.F. and further investigation into its causation and prevention is
urgently required, especially as there is the chance of a mild spirochaetal
disease developing under suitable conditions into a serious one.

REFERENCES.

[I] Burnett, W., “A Practical Account of Mediterranean Fever,” 1814. [2j Pym, W.,

“Observations uponBulam, Vomito-negro, or Yellow Fever,” 1848. [3J Birt, C., “ Phlebotomus

Fever in Malta and Crete,” Journ. Hoy. Army Mrd. Coins, February, 1910, pp. 142 and 238.
[41 Report of the Barrack and Hospital Commission, Mediterranean Stations, 1863, pp. 97-99.
[5J Report of the Commission on Mediterranean Fever, 1906, pt. vii, p. 223. [6] R.A.F. Health

Report for 1920, i, p. 54. [7J Army Medical Report, 1823. [8] Marston, J. A., “Simple Con-

N—W 16

14 Whittingham: Observations on Sand-fly Fever in Malta

tinued, Ephemeral, Febricula or Maltese Fever,” Army Medical Report , 1861, p. 504. T9]

Dokrr, R., “Das Pappatacifieber,” 1909, p. 101. [10] Wenyon, C. M., Trans. Roy. Soc. Trap.

Med. and Hygiene , 1921, xv, p. 163. [11] “ The Reaction of Media,” Medical Research

Committee, Special Report Series, No. 35. [12] Hennan, J., “Medical Topography,” 1830.

[13] McCarrison, R., Indian Med. Gaz. t 1906, xli, p. 7. [14] BlRT, C., “ Phlebotomus Fever

and Dengue,” Trana. Soc. Trap. Med. and Hygiene , 1918, vi, p. 250. [15] Balfour, A.,

Sup. Third Report, Wellcome Research Laboratory, 1908, p. 38. [16] Harnett, W. L., Indian

Med. Gaz. y 1913, xlviii, p. 45. [17] Whittingham, H. E., and Sims, C., “Some Observations

on the Bacteriology’ and Pathology of Influenza,” Lancet , 1918, ii, p. 865. [18 j Gulland, G. L.,

and Goodall, A., “The Blood, a Guide to its Examination, Ac.,” 1914, p. 281. [19] Byam,

“ Trench Fever,” 1919, p. 87. [20] Memoranda on Medical Diseases in the Tropical and Sub¬
tropical War Area, 1919,p.l98. (21J Coi VY, Bull. Soc. Rath. Exot ., Paris, 1921, xiv, p. 447.

[221 Griffith, A. $., “ The Cultivation of Spirochmta icterohsemorrhagim and the production of
a Therapeutic Anti-Spirochietal Serum,” Journ. Hygiene , 1919-20, xviii, p. 63.

Mar Section.

President—Sir John Goodwin, K.C.B., C.M.G., D.S.O., A.M.S.

Venereal Disease as a War Casualty.

By Surgeon Bear-Admiral William Bett, M.V.O., R.N.

In all recent wars the problem of venereal disease has been a pressing
one, not that there is usually more disease during war, but because in war
every man is urgently required. I have a few figures and tables showing
the incidence of venereal disease in various forces and at various times ; it
will not be necessary to burden you with many of these. Lookipg back, we find
there has been a very marked improvement in the British Army and Navy since
1860.

The incidence per 1,000 of strength in the Army was, in I860, 316 ; in
1895, 238; in 1911, 114; in 1912, 56; in 1921, 40; in 1922 (first half), 34.
In 1888 the percentage of venereal diseases to all diseases was 30*7 ; in 1912,
16'3; in 1921, 7'5. It is remarkable that in 1888 the number of cases of
gonorrhoea and syphilis was approximately the same; in 1912 the proportion
is estimated as 3 gonorrhoea to 2 syphilis; in 1921, 3 3 gonorrhoea to 1
syphilis (Southern Command).

In the Navy, in 1870, the admission ratio was 98 ; in 1888, 154; in 1913,
93; in 1915, 67.

As regards early wars we have little precise information. Syphilis was
almost unknown in Europe until near the end of the fifteenth century. It
appears to have been first really noticed soon after the return of Columbus and
his followers from the discovery of the Western World, and to have been dis¬
seminated over Italy, France, Spain and England by the demobilized adventurers
of the army of Charles VIII of France that had besieged Naples. Complete
absence of immunity and lack of proper treatment were the probable causes of
its rapid spread and great virulence. It is remarkable that the disease was not
at first recognized as “ venereal ” (this is probably explained by the com¬
paratively long incubation period). Its venereal origin, however, was acknow¬
ledged by 1519, and Ulrich Van Hutten, writing in that year, says that
the disease was then less virulent than when it first appeared. Van
Hutten himself contracted the disease, and was under the impression that
he cured himself with guaiacum after failing with mercury.

Gonorrhoea appears to have been known in all countries from the earliest
times: the word is first found in the writings of Aretaios of Cappadocia in
the first or second century A.D. ; the disease is, however, allude! to in the

F—W 1 [November 18, 1922.

Bett: Venereal Disease as a War Casualty

Papyrus Ebers, the oldest Egyptian medical record, and in the Book of
Leviticus ; it is also said to be well described in a Japanese manuscript of about
900 B.C. Great confusion in nomenclature existed until almost recent times,
and certainly as late as 1830 some reputable physicians affirmed that
syphilis, gonorrhoea and chancroid were essentially the same disease.

Very little is said about any form of venereal disease by the military
historians of the sixteenth, seventeenth and eighteenth centuries, yet we know
from other sources that these diseases were prevalent in armies and were very
severe. The Duke of Alva's army in Portugal, in 1579, suffered from a very
virulent form of venereal disease ; it is said that amputation of the penis for
phagedaena was performed in 5,000 cases. This general (the Duke of Alva)
was a believer in the regulation of prostitutes; he organized them into bands,
with uniform and mounted officers ; any member of this force lacking a health
certificate might be ordered 200 lashes. Another well-known general,
Strozzi, believed in the suppression of prostitution, adopting on one
occasion the barbarous method of throwing 800 prostitutes into a
river.

In 1706, an Anglo-Portuguese army near Madrid was so badly infected by
prostitutes, said to have been sent from that city for this express purpose, that
6,000 cases are said to have been in the hospitals, of whom the greater number
died.

It was supposed that syphilis was very prevalent in the French army
during the eighteenth century (two out of every three soldiers said to be
syphilitic).

In the Peninsular War the official history hardly alludes to venereal disease,
but in a paper read by Ferguson 1 before the Medical and Chirurgical Society
of London, it is stated that a very severe type of disease occurred; there was
some idea that the Portuguese did not use mercury, and for this reason
had developed a certain racial immunity while the virulence of the disease
remained unabated. The total number of cases is said not to have been very
great (about one to thirty-six of all diseases), and the reasons for the
small number of cases are given as hard work, strict discipline, and absence
of opportunity.

In the Crimean War the army does not appear to have suffered very
severely from venereal disease. It was noted that in most cases the
disease had been contracted at home. In the Navy, the incidence in the
Baltic Fleet, where there was frequent communication with various ports, was
47 per 1,000 ; in the Black Sea Fleet only 20*6 per 1,000.

In the American Civil War the facts as regards syphilis are instructive (I
have not got the figures for all venereal diseases). The general incidence-rate
per 1,000 which had for many years ranged in the neighbourhood of twenty-five,
remained much the same for some time. In 1865, however, when the war
was practically over, it rose rapidly, and during three years, 1867-68-69, was
over 100 per 1,000. It fell gradually to 9*3 in 1899, but rose gradually again
to 25*5 per 1,000 in 1909.

In the Franco-Prussian War the German rate per 1,000 for all venereal
disease was approximately 42; these cases were about 7 per cent, of all sick
cases, that is to say excluding wounds in action, &c. Very strict measures
were taken for the regulation of brothels, and the registration and examination
of prostitutes. The ratio rose after the war, but fell in a short time. Since

i Med. Chir. Trans., 1813, iv, pp. 1-16.

War Section

1874 the admission rate for all venereal disease has been lower in the Prussian
Army than in any other.

During the South African War the incidence of venereal disease in the
Army was diminished. There was some increase after the war.

The Late War.

It is difficult to get precise figures as to incidence of venereal disease.
In 1917, from 7,500 to 9,000 men were constantly in hospital in the United
Kingdom suffering from venereal disease—a total of 54,884 admissions:
annual rate per 1,000 of strength, 43. In France during the same year, it
may be calculated that there were as a rule 8,000 cases constantly in hospital.
In the Egyptian Army the incidence was about 46*8 per 1,000 in 1915,
and in 1917 about 32. According to one estimate, during about two and a half
years of war, English hospitals took in 70,000 cases of gonorrhoea, 21,000 cases
of syphilis, 6,000 cases of chancroid, and it is said that during the same period
about 40,000 or 50,000 cases of syphilis and 150,000 to 200,000 cases of
gonorrhoea occurred in France. In one camp of Canadians 5,250 cases
of venereal disease occurred in one year (numbers not known).

I do not vouch for the absolute accuracy of these figures, but at any rate
they give some idea of the situation.

At a time when every man was most urgently required, approximately
20,000 men were constantly sick from one disease alone, and that, a disease
which must be looked upon as to a large extent preventable; nor does the loss
stop there by any means. These cases occupied large hospitals and large
medical and nursing staffs which would otherwise have been available for
other sick and wounded. Their transport to and from hospital, and transport
for their reliefs, added largely to difficulties already great enough; and although
they were kept in hospital for long periods in order that they might return to
the fighting line as fit men, it may be looked upon as certain that many of them
would not really recover their full strength and vigour for a very considerable
period. Some of course were permanently incapacitated and had to be
invalided.

I believe the stay in hospital of a venereal case in France averaged nearly
two months, though many of them occupied a good part of this time in
undergoing physical training.

The main question to be considered is : What steps can be taken to reduce
the incidence of venereal disease in the Army and Navy in future wars and
during peace.

Here I will quote a remark made by a very able and experienced Army
Medical Officer, from whom I have had much valuable help in preparing
this paper. He said : “I do not think the title of your paper is sound;
venereal disease is not, properly speaking, a war casualty at all. These
diseases are prevalent in the civil population in peace, much more prevalent
than is popularly supposed. In the late War they came from the civil
population to the Army and Navy, where they were discovered, diagnosed
and tabulated. People are apt to talk as if the Services were a sort of
reservoir of venereal diseases from which they spread abroad; the exact
contrary is the case.” This point will again be alluded to.

A great deal has been done, and is being done, in the way of prevention,
both in the Services, and what is equally, or more important, among the civil
population. In both Services, lectures are given to all ratings ; in these

Bett: Venereal Disease as a War Casualty

lectures, the possibility and the advisability of living a clean life is dwelt upon,
not merely for the sake of avoiding venereal disease but on account of higher
ethical and social considerations. As it is quite certain that this excellent
advice will be frequently disregarded, some account of the possible consequences
of impure intercourse is given in the lectures and measures for personal
prophylaxis are described in detail. The necessity for reporting any venereal
disease at once is always strongly insisted on. Men are made acquainted with
the earliest symptoms in order that they may be able to do this.

It is our experience in the Navy, and I am also told the same holds true in
the Army, that concealment of disease is now quite uncommon, and, in fact,
it is an ordinary occurrence for men to report, who think they may have
contracted venereal disease in whom no symptoms whatever can be detected.

The modern treatment of syphilis by the organic arsenical compounds,
constituting perhaps the greatest advance in medical science that has been
made for centuries, is, in itself, a most valuable means of protection to the
community. If men report the moment a sore is noticed, the spread of
the disease is limited both directly—for many men formerly continued their
sexual habits long after the first appearance of a chancre—and, ultimately, the
chance of complete cure being so much greater.

The treatment of gonorrhoea has, unfortunately, not advanced in the same
way: still, the prospect of complete cure is much better when the disease is
seen in an early stage.

It is not proposed to enter to any extent into the controversy with which
we are all so familiar, between the societies for “ combating ” or for
preventing ” venereal disease. But my opinion is that this evil is so great
and so widespread, so terrible in its effects, so fatal to our national efficiency,
both during war and peace, and so apt to involve the innocent wives and
families of those who have contracted disease through their own imprudence,
that almost any measures are justifiable if only they are efficient.

In the Navy, for many years, men have been provided with disinfecting
materials—packets. The packet system may be said to include the issue of
ointments, solutions or condoms for the purpose of personal prophylaxis.
All these have been recommended in the past and are not so modern as they
are thought to be. Dr. Conton, a French physician, practising in London,
invented condoms in the reign of Charles II. Sir William Forsyth recom¬
mended the application of mercurial ointment as a prophylactic in the year 1767.
John Hunter advised corrosive sublimate solution in 1786 for the same purpose.
De Piacenza, writing as early as 1474, advises “ washing thoroughly immediately
after coitus as a means of preventing corruption.’’ His book is quoted by
Swediaur, who found it in the library at Bologna.

One objection to * packets ” of any kind is that they are not quite reliable.
They are not reliable because they are often not properly used. This is what
one would expect, taking into consideration not only the circumstances, the
excitement, or the apathy, frequently the partial intoxication, of the men who
have to use them, but also the fact that they are likely to be mislaid, or in the
case of solutions, spilt, or, in the case of condoms, used in a filthy condition.
It has to be remembered also, that the act of coitus is often repeated several
times, this making it virtually impossible for a man to have a sufficient supply
of material.

I believe that the best method of prophylaxis for men consists in thorough
washing with soap and water immediately after the act, together with mictu¬
rition, and I think that great stress should be laid on this in all lectures :

War Section

immediately —that is the great point. It is true that soap and water are not
always available in houses and rooms used ; they ought to be—they often are—
and if men insisted on them they would be more often there ; men will insist
on them if properly impressed with the necessity. Ointments or lotions can
be used—should be used in addition if available.

I am aware of the objection that intercourse often takes place out of doors,
in lanes, hedgerows, &c .; but I do not believe that there is much chance of
ointments or lotions being properly used under these conditions, and a man
should be advised, even if he uses them, to make his way, as soon as possible,
to some place where he can wash himself thoroughly. Here comes in the
importance of the ablution room. This should be provided with trough and
taps at suitable heights and should be supplied with disinfectants which
may be applied with the maximum efficiency after thorough cleansing of
the parts. Warm water should be supplied if possible. Ablution rooms are
being fitted up in large numbers of naval establishments and ships and
are proving of great value.

I may say that in my opinion, condoms are more efficient (if properly used)
than either lotions or ointments, and I find this view advocated by German
medical officers of experience.

Extraordinarily good results have, it is true, been reported both in the
Army and Navy from the use of permanganate of potash solution only, but we
have to be careful before drawing the conclusion that low incidence of venereal
disease, following the adoption of any given measures, has been actually and
solely due to those measures.

The incidence varies a good deal owing to a large number of conditions.
Some regiments have been known to suffer habitually more than others ; the
advent into any district of a number of badly diseased women, or conversely,
of a number of healthy or recently treated women would be a deciding factor,
one way or the other.

One difficulty in drawing precise conclusions, arises from the fact that we
are never able to tell how many men have taken no precautions and still
escaped disease, or how many have escaped after using precautions. Sir
Jonathan Hutchinson said that he thought disease was contracted about
once in a hundred serious risks and his opinion on a point of this sort
carries a good deal of weight, though I cannot help thinking his estimate is
too low.

Another difficulty consists in the fact that one cannot believe the state¬
ments made by men who have contracted disease as to the precautions taken.
Again, all lecturers inculcate the desirability of living a chaste life; none but
a most confirmed optimist expects this advice to be taken by all his hearers.
On the other hand, it may be, and probably is, taken in some instances.

It seems to me quite clear, however, that the use of packets and the
employment of preventives of this nature have had a very large measure of
success in diminishing disease, and that they should be issued to men in the
Services who should be instructed in their use, as well as to the necessity for
thorough cleansing of the parts at the earliest possible moment. One can
hardly imagine what the state of this country would have been to-day but for
(a) Arsenical treatment , ( b) Prophylaxis.

Very good results are said to have been obtained in some United States
ships—every man w T ho went ashore in any suspicious locality was made to
cleanse and disinfect himself on returning to his ship, whether he admitted
exposure or not.

Betfc : Venereal Disease as a War Casualty

Any form of punishment either for contracting venereal disease or for not
using prophylactics is to be deprecated. It only leads to concealment and
subterfuge. About 1873, Lord Cardwell issued instructions for the punish¬
ment of men with venereal disease. This notoriously led to concealment and
eventually to a large increase in the number of cases of secondary syphilis.

The relation of alcoholic habits to venereal disease has been much
discussed. A certain amount of alcohol may temporarily stimulate the sexual
system, large amounts probably depress it; this is in accordance with what is
known of the effects of alcohol in general. Total abstainers are probably not
more chaste than other men. The real point is that alcohol lessens a man’s
power of discrimination, and lowers his standards so that he has recourse to
degraded women, with whom, if sober, he would be ashamed to consort.

Dr. Lomholt, of Denmark, made observations on about 500 cases in which
he was able to obtain some history of the origin of the disease, and the man’s
state when it was contracted ; and his results, as far as they go, rather bear
out the above remarks which, I believe, are also in accordance with the
recently expressed opinion of Major Harrison.

Very hard work and very small pay have been advocated as likely to
minimize venereal disease, and these conditions did, probably, largely account
for the small amount of disease in the German army; they can hardly be
thought of in a voluntary force.

I may say here that I object to the term “ misconduct ” as applied to men
who contract venereal disease; as medical men we are not judges of conduct,
and if we were, we should have to make allowances for young, full-blooded men,
well fed and but imperfectly instructed, placed under entirely unnatural
conditions and exposed to the strongest of all temptations. Therefore I do
not think we should talk much about misconduct .

Apart from these considerations, a certain number of men contract venereal
disease from their wives; no doubt they form a small proportion of the whole,
but it is probable that their actual numbers are under-rated. Many men are
too proud to mention the disgrace which seems worse than the disease.

(a) Measures in the Services.

The importance of encouraging healthy and manly games and sports among
the men of both Services cannot be too strongly insisted upon—a man who
wants to keep fit will not infect himself with venereal disease if he can help it.
It is also most essential to provide men with other interests, reading and
recreation rooms and the like where he can be comfortable; lectures on
interesting subjects, opportunities for instruction in handicrafts, and so on ;
also concerts or theatricals in which men can take part. It is fair to say that
nearly all senior officers of both Services are alive to the necessity of these
things, and that every effort is made by the Admiralty and the War Office to
provide facilities for them.

( b) Venereal Disease in Civil Population.

To what extent does venereal disease exist in the civil population ? This is
a most difficult question to answer. Many investigations have been undertaken
in various countries at various times and with various results. In a report
issued in 1868 it was stated that 6‘92 per cent, of all patients at certain insti¬
tutions were the subject of venereal disease clinically; 33 per cent, of all

War Section

prostitutes were thought to be infected—this was probably far too low an
estimate.

Some investigations made at the London Hospital showed that among 1,000
patients under treatment for other diseases 10*3 per cent, of males and 5*1 per
cent, of females had positive Wassermann reactions.

Sir John Collie, as a result of the clinical examination of 1,119 cases of
accident and of 557 presumably healthy persons examined for purposes of
their work, found that the case percentage of venereal disease was 5*5. He
also had the blood of 491 apparently healthy persons subjected to the Wasser¬
mann test—9*36 per cent, of the tests were positive.

In fourteen asylums, representing all classes of the community, 15*4 per
cent, of bloods yielded a positive Wassermann reaction. Sir Frederick Mott 1
found that Poor-Law infirmaries in London yielded 19*9 per cent, of positive
blood Wassermann reactions: mothers of new-born infants in Shoreditch, 19*7
per cent, positive; mothers of new-born infants in St. Pancras, 6*6 per
cent, positive; unmarried mothers in Shoreditch, 27*6 per cent, positive.

General mortality-rates are misleading, and practically no Importance can
be attached to them. It has been estimated that 27,000 deaths (antenatal
and in first fourteen days of life) occur annually in England and Wales
from venereal disease.

Experienced persons, for whose opinions I have recently asked, have
estimated the amount of venereal disease among urban populations as at nearly
10 per cent. I think this is probably too low.

Investigation by various methods on bodies examined post mortem
resulted, approximately, in 7 per cent, showing some signs of venereal disease.

Both in America and Germany it has been thought by competent observers
that the rate of incidence on adult males in civil life was higher than in the
Army (for corresponding ages). One thing, and that the most important, is
quite certain ; the number of cases in an actively contagious stage is infinitely
greater among the civil population.

The question of what steps in the way of prevention should be taken among
the civil population is a very vexed one. Very important steps have been taken
in the provision of free treatment on the most approved lines at clinics where
all the necessary blood tests and other bacteriological examinations, &c., can
be carried out. The following figures are of great interest:—

Civil Population Measures. Clinics.*-
Ministry of Health lie port, 1920. Duration and Effects of Treatment.

Syphtli*

, Gonorrhoea

Total

(1) Number of persons dealt with during 1919-20.

Vl ) Number of persons stopping—

105,619

87,792 |

193,411

(✓/) Before completing a course of treatment.

30,459

28,869 i

59,328

[b) After treatment, but before final tests as to cure

9,350

6,481

15,831

13) Number of persons discharged after completion of
treatment and observation

H,240

13,300

21,540

(4) Number of persons who, on January 1, 1921, were
under treatment and observation

47,894

28,822

76,716

1 Report of Royal Commission on Venereal Disease, 1914-16; and Brit. Med. Journ ., 1916,
i, p. 346.

2 Brit. Med. Journ. October 8, 1921, p. 566.

Bett: Venereal Disease as a War Casualty

I am informed that there has been a considerable falling off (something like
20 per cent.) in the attendance at these clinics since 1920.

(a) Weak Points .—One obvious weak point is that so many patients leave
before they are cured. Another, less obvious, is that many prostitutes (among
others) do not go at all, being afraid of losing their occupations if it should
become known they were attending, and no doubt for other reasons.

(b) Notification. —Notification of venereal disease to medical officers of
health has often been proposed, but has not been favourably reported upon.

One scheme has been proposed which seems to me to possess certain merits.
It is that medical officers of clinics or private practitioners should notify medical
officers of health whenever a patient suffering from venereal disease in a con¬
tagious form is found not to be attending for the proper treatment.

It is proposed that the medical officer of health should then communicate
with the person in question, and if he or she still refused or neglected treatment
that this should be made a punishable offence and dealt with accordingly.
The one drawback that I can see in this scheme is that it might lead to in¬
creased numbers of persons, especially prostitutes, avoiding the clinics alto¬
gether. This point will be alluded to again.

Information as to venereal disease and the dangers of promiscuity should
certainly be given to civilians. The information need not be very detailed, and
though preserving to a certain extent an open mind on the matter, I am rather
opposed to the film and lantern methods, whether as used in the Services or
among civilians. Verbal pictures should not be painted with too black a
brush. A moderate statement of the subject is sufficient, anything more tends
to produce syphilophobias and similar conditions among the healthy and undue
depression and despair among the diseased.

After considerable hesitation I have come to the conclusion that some
information as to personal prophylaxis should be given to young men, but not to
young women. This point, however, should, in my opinion, be decided by
medical women. Needless to say, all instruction on these subjects should be
given with the greatest care and discretion, and I should recommend the
appointment of State lecturers for this purpose.

The fact that large numbers of prostitutes do not attend clinics, and that
those who do frequently cease to attend before they are cured, and are often
known to be pursuing their trade while in an actively contagious condition, led
me to make a study of the Contagious Diseases Acts of the sixties. I began by
being entirely opposed to these Acts, but have now come to the conclusion that
in a modified form some measure of this description is absolutely necessary if
any considerable further reduction in venereal disease is to be brought about r
for there is a reservoir of venereal disease in the prostitutes of this country.

(d) Civil Population Measures.

Contagious Diseases Acts .

The history of these Acts in this country is briefly as follows :—

In 1864 an Act was passed which allowed the compulsory examination of
prostitutes known, or suspected for good reasons, to be diseased, and for their
treatment if found to be diseased, in certain hospitals. This Act was applicable
to certain districts—naval and military stations.

In 1866 this Act was repealed and another one passed, authorizing the
compulsory examination of women as to whom satisfactory evidence could
be obtained that they were prostitutes—if diseased they could be detained in

War Section

certain hospitals (lock hospitals provided under the Act) up to a period
of six months. They could be ordered to attend periodically for medical
examination—fortnightly. They could be relieved from these regulations on
producing evidence that they had ceased to be common prostitutes.

Owners or occupiers of brothels could be fined £20 or imprisoned for
six months, with or without hard labour, for allowing diseased prostitutes
to resort to their houses for purposes of prostitution. In 1868 and 1869, the
provisions of the Act of 1866 were somewhat extended.

Numerous committees inquired into the working of these Acts and practi¬
cally all reported that they were beneficial.

A Eoyal Commission in 1871 made a remarkable report. The members
said: “ These Acts have purged the towns and encampments to which they
have been applied of miserable creatures who were mere masses of rottenness
and vehicles of disease, providing them with asylums where their sufferings
could be temporarily relieved, even if their malady was beyond cure, and where
their better nature was, probably for the first time, touched by human
sympathy.’* They said they had found no instances in which the police has
abused the powers entrusted to them. They found that the Acts had had a
beneficial effect on the health of the men of the Army and Navy. They found
that the Acts tended to deter women from becoming prostitutes, that owing to
them, an increasing number of women were reclaimed, and that they had a
distinctly deterrent effect on juvenile prostitution. They actually recommended
the extension of the Acts throughout the country, but they advocated the
abolition of power for compulsory periodical examination of all prostitutes,
They recognized to a certain extent the value of this, but they thought that it
would be unpopular in the country generally, and that its place could be taken
by voluntary examination with power to detain diseased women in hospital.

A Select Committee sitting in 1882, endorsed to a large extent, the report
just alluded to. They said the repeal of the Acts would result in:—

(a) Full license for venereal disease of all kinds to disseminate itself
unchecked, either by police control or voluntary treatment.

(b) A serious diminution in the effective strength of the Army and Navy,
which would be especially felt in the event of their services being called into
requisition.

(c) The relegation of numbers of these unhappy women to the state of
hopeless misery, squalor and disease, in which they lived before the system
was introduced.

(rf) The letting loose of increased crowds of abandoned and diseased women
and girls of all ages, upon streets and thoroughfares swarming with soldiers
and sailors.

The Select Committee believed that the extension of these Acts to the
United Kingdom generally would be desirable and beneficial, but they did not
recommend this on account of public opinion. They strongly recommended the
continuance of the Acts in the districts in which they were then in operation.
They advised the institution of lock hospitals in unsubjected districts for
voluntary treatment. They made certain other recommendations strengthening
the Acts.

The Committee were not unanimous, and a minority report recommended
abolishment of compulsory examination of prostitutes, and the minority report
w T as acted upon, and this, considered by most people the most useful feature
of the Acts, was abolished in 1883.

Bett: Venereal Disease as a War Casualty

Results of Modification and Ultimate Repeal of Acts.

The figures refer to a period of ten years during which the Acts were fully
operative from 1870 to 1882 :—

Fourteen Stations under Act Fourteen Stations not under Act

Average strength ... 47,394 Average strength ... 19,218

Total admissions (S. 1) ... 31,105 Total admissions (S. 1 ) ... 29,582

A short calculation shows that more than 40,000 cases of syphilis and that
more than 12,000 cases of gonorrhoea were apparently prevented by Act.

The admissions per 1,000 for the same period were :—

Fourteen Stations under Art Fourteen Stations not under Act

Syphilis ... ... 50 Syphilis ... ... 118

Gonorrhoea ... ... 84 Gonorrhoea ... ... 105

Constantly in hospital, same period :—

3*97 9 16

The proportions became rapidly equal when the Acts were repealed. The
modification in 1883 was disastrous.

1888

1SS4

188

138

160

The Acts were less efficacious with regard to gonorrhoea than syphilis on
account of the impossibility then existing of diagnosing gonorrhoea in women
in whom discharges of other descriptions are common. The Acts were then
generally found to be useless and were repealed in 1886.

I believe that these Acts did an immense amount of good, and it is
probable they might have done still more good had they been persevered with
and extended. I also believe that the strongest objections to them would be
removed if the investigation duties were undertaken by women, and the
medical examinations carried out by women doctors, though I am, of course,
aware that the general feeling—the feeling of women and women doctors in
particular—is opposed to this.

The argument that the Acts discriminated unfairly as between men and
women, can, I believe, be rebutted ; not because I think that prostitutes are
worse, morally or socially, than the men who resort to them, nor because—
poor creatures—they prosecute their dreadful calling for monetary considera¬
tion (I refrain from pronouncing any moral judgments in these matters), but
because the worst consequences of venereal diseases fall on women ; not only on
the unfortunate prostitute, but on the innocent wife, who sees her own life and
the lives of her children poisoned and maimed, and has no remedy. Is it not
a fact that women’s hospitals are crammed with the victims of gonorrhoea ?
For the sake of womanhood, women should be prepared to make sacrifice, to do
unpleasant work, even to risk occasional indignity.

If I were asked what class of people in this country I most reverenced and
admired, I should say the mothers of the poorer classes. Many of the lives of
these women are continuous acts of heroism and self-sacrifice. It is these
women I wish to protect, both for their own sakes and for the sake of the
strong sons they should bear to the Empire.

We must either end prostitution or mend it. Supposing any body of persons
were to say : “ We abhor the drink traffic, we decline to lend any countenance

War Section

to it, we will not license it or regulate it or do anything which might possibly be
construed into recognition of it. We will, therefore, allow any kind or quantity
of drink to be sold anywhere and by anyone, provided it is not drunk in public
places during daylight or in brightly lit streets at night.” The parallel is
almost exact.

We have accepted the fact that prostitution cannot be abolished, and,
broadly speaking, we sit with folded arms. One difficulty is, of course,
clandestine prostitution. I have no doubt that this would be much increased,
anyhow, for a time, by any determined attempt at the closing of all brothels.
On the other hand, almost all the evidence is in favour of the view that the
old Contagious Diseases Acts tended to prevent or limit it.

Remarks by Lieutenant-Colonel P. H. Henderson, R.A.M.C., M;B.

I have been asked by the Secretary to give my views, based on any experi¬
ence I have had, on the following points :—

(1) Men deliberately acquiring venereal disease with the object of escaping
service in the front line.

(2) The conditions, if any, under which men suffering from venereal disease
might be made to serve in the front line.

(3) The question of maintaining discipline in hospitals for venereal diseases.

With regard to (1) I have never known of British troops deliberately

acquiring venereal disease with the view to escaping service, but a good many
instances occurred amongst the Cyprist and other transport drivers with
certain British units in the Salonica Army. Men with gonorrhoea disposed of
swabs covered with urethral discharge to their friends at various prices. Others
bought condensed milk which they poured down their urethra in the hope
of deceiving the medical officer, and adopted various other devices for
simulating venereal disease. These men are dealt with under Section 18 of
the Army Act.

(2) I do not consider that any man suffering from gonorrhoea, even in the
later stages of gleet, should be returned to duty in the front line. He should
be kept in hospital until cured.

Men suffering from syphilis should be kept in hospital until all physical
signs have disappeared ; and their return to front line, or other units, would
depend on the military situation and the facilities for continuation of treatment
which could be arranged at a conveniently near medical unit. Of course, in the
event of urgent military necessity, venereal patients would be turned out of
hospital and sent to front line units, and the best arrangements possible made
for their treatment.

(3) In my opinion the chief difficulties in maintaining discipline in venereal
hospitals during the war were due to the hospitals being used solely for venereal
patients, and being designated “ venereal hospitals.” The name cast a stigma
on the hospitals, and the patients disliked going to them. The patients were
apt to look upon themselves as prisoners and not as patients in such places,
with the natural result that they rapidly lost their self respect and became
intolerant of discipline.

To my mind the solution of this problem lies in providing venereal centres
as special departments of general hospitals, where the afflicted feel that they
are being treated not as prisoners and criminals but as ordinary sick men.

Further, as soon as their disabilities will permit of it, venereal patients
should receive as much exercise in the form of work and games, as is com¬
patible with the efficient treatment of their disease.

Bett: Venereal Disease as a War Casualty

DISCUSSION.

Lieutenant-Colonel P. H. Henderson said that those officers who were present in
February when he (Lieutenant-Colonel Henderson) read a paper on this subject before
the Society of Medical Officers of Health, or who might have subsequently read his
paper in the Journal of the Royal Army Medical Corps , would appreciate how closely
his views were in agreement with those of Surgeon Rear-Admiral Bett. As a matter
of interest, and with the permission of Sir Alfred Blenkinsop, D.D.M.S., Eastern
Command, he would give a few figures regarding gonorrhoea and syphilis which
substantiated certain statistics which Surgeon Rear-Admiral Bett had given them.

Gonorrhoea

Syphilis

Eastern Command.

Equivalent Annual Batio per 1,000 of Strength :—

Cases contracted with their units in the

Year

All cases

command, or while on furl
detached from their un

1913

24*15

Not available

1921

2012

. 14-75

1922

(9 months)

21*48

. 11*83

1913

16-3

Not available

1921

. 217

1922

(9 months)

6-9

. 212

It would be observed that there was a very marked reduction in the incidence of syphilis*
but a comparatively slight reduction in the incidence of gonorrhoea. Now, in his opinion*
medicinal prophylaxis as at present carried out, was chiefly accountable for this change
in incidence—syphilis infection, being mostly extra-urethral, was more easily prevented
than gonorrhoeal infection which was intra-urethral. Some doubted the value of early
disinfection, but how otherwise could this sudden reduction in the incidence of syphilis
be explained ? Although, doubtless, a slight decrease might be attributable to better
facilities for recreation, a greater interest taken in the men’s welfare by the officers, &c.,
one would expect such factors to bring about an equal reduction in the incidence of
gonorrhoea and syphilis, but from the figures just given it was apparent that this was
not the case. How then could the reduced incidence in syphilis be explained ? The
present-day soldier was better fed and better paid than the pre-war soldier, and the
average recruit was more illiterate and not so well disciplined as the pre-war recruit,
and these were all factors which would rather tend to an increase in venereal incidence.
With the introduction of a better prophylactic outfit and more suitable instructions as
to its use, gonorrhoeal infection might also, to a large extent, be prevented.

He understood Surgeon Rear-Admiral Bett to say that the title of his paper w*as
really w r rong, as the incidence of venereal diseases was not greater in war than in peace
and that such diseases could therefore not be looked upon as war casualties. He did
not altogether agree with this view. It depended on the theatre of war in which
they were serving. He (Lieutenant-Colonel Henderson) had served for about a year in
Transcaucasia and there the incidence of venereal diseases was very high indeed and
necessitated the conversion of three field ambulances into hospitals for venereal
diseases. He therefore considered it most important that in war special arrangements
should be made in advance for the reception of venereal cases and that it should not be
necessary to admit them with wounded and sick to any hospital w f here special facilities
for their treatment did not exist. Special venereal centres ought to be provided, but
these should not be isolated hospitals labelled w'ith the title “hospital for venereal
diseases.” They should form part of a general hospital. Every officer with experience
of such matters knew of the innumerable difficulties associated w'ith the administration
of venereal disease hospitals during the late war. The stigma attached to them had
lowered the self respect of the men and this had led to breaches of discipline and
numerous other troubles. These troubles were avoided when venereal patients were
treated, not as outcasts, but as ordinary patients, in a special department of a general
hospital.

War Section

He was not absolutely sure what methods, legislative and otherwise, Surgeon
Rear-Admiral Bett recommended for dealing with the venereal disease problem.
Until they learned to look upon these diseases in the same light as they looked upon
other important contagious diseases, and dealt with them on similar lines, not only in
the Services but in the civil community, they could never expect to achieve satisfactory
results. His motto was: “ Prevent them if you can by the use of all legitimate means,
and if you cannot prevent them, insist on the patients coming under treatment at the
earliest possible moment and remaining under treatment until they receive a certificate
of cure from their doctor.” For the purpose of this certificate a definite standard of
cure for each disease must be laid down and legislation must be introduced enforcing
disciplinary action when patients failed to continue treatment until cured.

Major-General Sir \V. G. MACPHERSON regretted that he was not present at the
commencement of the reading of Admiral Bett’s paper, but he understood from what
Colonel Henderson had just said that Admiral Bett did not regard venereal disease as
a war casualty. If this was so, he was in cordial agreement with Admiral Bett’s
opinion. With 10,000 venereal patients constantly sick in hospital and an average
duration in hospital of two months, it was not difficult to see that in a strength of some
two million or so the incidence, reduced to admissions per thousand of strength, would
be comparatively small and in fact in no way excessive as compared with peace-time
rates. Colonel Henderson had cited the incidence amongst the troops in the Caucasus
as evidence of venereal disease being undoubtedly a war casualty, but it should be
remembered that the incidence of venereal disease in peace time in certain localities
in the East was extremely high, and, in order to prove that venereal disease was a
war casualty because it was excessive in the Caucasus, one ought to compare that
incidence with what would be the normal incidence of venereal disease in the same
locality in time of peace. Colonel Henderson had also referred to a paper which
he (Colonel Henderson) had read before the Society of Medical Officers of Health, and
Sir W. G. Macpherson referred to the fact that in the discussion on that paper
he (Sir W. G. Macpherson) had said practically the same as Admiral Bett, namely,
that the simplest and best method of preventing the disease was to wash and be clean.

Major A. T. Frost said he thought that the present system of prophylaxis needed
simplification. He had questioned men who came to hospital suffering from venereal
diseases and found that nine men out of ten did not use the present packet efficiently.
The ideal packet should contain in one tube antiseptics against both syphilis and
gonorrhoea. Calomel cream had been proved by experiment to be efficient against
syphilis and if a salt such as oxycyanide of mercury were added in a strength of one in
a thousand to the calomel cream it would be an advance on the present packet, and 1
active against both diseases. Soap, in the form of soft soap, placed inside a small swab
of cotton wool would be an advantage in any form of packet as an additional safeguard.

In war time, either a general hospital or part of one, should be equipped as a
venereal hospital of the first expeditionary force. Experience had shown that the
medical equipment of a general hospital was not convertible for the efficient treatment
of venereal diseases. A special scale of equipment should be added to army medical
tables to meet the requirements of a venereal hospital.

Surgeon Rear-Admiral Sir Percy Bassett-Smith said that it was a common
misconception of people in civil life that the Services brought venereal diseases to the
shore, whereas the opposite was almost always the case ; it was the healthy blue-jacket
who contracted the disease from the infected shore population. Experience of clinics
in London showed how widespread was the infection on shore. Venereal diseases were
infective diseases and could only be stamped out by methods used for other infective
diseases, namely, notification, isolation, &c. This the public would not at present
tolerate, but there was an increasing opinion that those who ceased to attend clinics
before being cured, which was a common event, should be held responsible for any
spread of infection and should be controlled. If this were done it would be the thin
edge of the wedge for more complete notification.

Bett: Venereal Disease as a War Casualty

Major-General Sir Alfred Blenkinsop said that the importance of efficient treat¬
ment of venereal disease had been referred to more than once. They could not too
strongly insist that efficient treatment was the primary means of preventing the spread of
venereal disease. They hard heard of the large proportion of patients attending venereal
disease clinics who discontinued their attendance long before a cure was established.
Such people were a very grave danger to the public, and some means should be con¬
trived to compel them to continue treatment until they had reached a standard of cure
which should be definitely laid down and rigidly adhered to. He was convinced that
one of the causes of the great reduction of the incidence of venereal disease in the
Army was that all cases were now kept under treatment until they were definitely no
longer likely to be a source of infection.

Admiral Bett referred to the influence of alcohol as a cause of infection. When
he (Sir Alfred Blenkinsop) was dealing with the prevention and treatment of venereal
disease in India, Lord Kitchener was Commander-in-Chief. He (Lord Kitchener) took
the keenest interest in the subject, and issued instructions that freedom from venereal
disease would be looked upon as a test of efficiency, and that any unit showing a high
incidence would not be selected for active service. He endeavoured to obtain figures
to show that men addicted to alcohol were more liable to fall victims to infection than
the more temperate, and he looked forward to producing statistics in proof of this when
addressing a meeting of the Army Temperance Association. He found, however, that
the incidence was, if anything, higher amongst the members of the Army Temperance
Association than amongst others. Whether this was due to the men who did not spend
money on drink having more cash available for other purposes he (Sir Alfred
Blenkinsop) was not prepared to say.

Perhaps the low incidence of venereal disease in the German and other conscript
armies as compared with the voluntary armies of England and America might be
accounted for by the conscripts being drawn from all classes of society, and being
trained under a territorial system which did not alienate them from the influence of
their families and friends and the girls they might hope to make their waves.

With regard to the conduct of venereal hospitals, venereal patients should be looked
upon as sick men and not as prisoners, and every effort should be made to maintain
their morale and self respect. For this reason it was advisable to treat these patients
in sections of hospitals to which general cases w ? ere admitted, rather than in
special institutions, at any rate in times of peace. Most of those present had had
experience of the great difficulty of maintaining a proper tone and due sense of
discipline in special venereal hospitals during the Great W 7 ar.

Colonel Henderson had spoken of the special opportunities of acquiring disease, and of
the special temptations to which soldiers and blue-jackets had been exposed in certain
phases of the late war. When he (Sir Alfred Blenkinsop) was Director of Medical
Services in Mesopotamia, the incidence of locally contracted venereal disease was low
as compared with that on other fronts, though they were constantly importing cases
from India; but when their troops advanced up the Persian road, and especially when
they reached Persia itself, venereal disease became a very serious cause of inefficiency.
The Persian women were, he believed, at no time remarkable for their sexual morality.
When they made their advance into Persia these women were in a state of great misery
and destitution, and were quite prepared to prostitute themselves in return for even a
ration biscuit. Unfortunately a large proportion of them were diseased, and special
precautions had to be taken to prevent them from infecting the British and Indian
troops.

Sir W. G. Macpherson had urged the importance of cleanliness as a means of
prevention, and with this he (Sir Alfred Blenkinsop) fully agreed. At the same time
he did not think this was the only precaution which should be taken. Colonel
Henderson and Major Frost were right in recommending the simplification of the
preventive outfit. Permanganate of potash was particularly objectionable as a con¬
stituent of this outfit, as it rapidly became oxidized and inert in solution, and it would
obviously be dangerous to supply it in crystals.

Surgeon Rear-Admiral Bett (in reply) said that he regretted that he had not had
the advantage of reading Colonel Henderson’s paper published in the Journal of the

War Section

Royal Army Medical Corps, but was glad to note a general agreement in their
respective views. He fully agreed as to the desirability of dealing with venereal
disease as with any other contagious disease. The measures he advocated were:

(1) Modified notification, as sketched out; (2) re-introduction of measures resembling
the old Contagious Diseases Acts, with modifications as mentioned; (8) an endeavour
to improve general social conditions; these in addition to measures being carried out
at present. The comparison was not an easy one, but he still thought that venereal
disease as a war casualty did not really exceed venereal disease in peace. He agreed
with Sir William Macpherson that a venereal hospital should be part of a general
hospital. 1

Addendum by Lieutenant-Colonel P. H. Henderson, R.A.M.C., M.B.

As Major-General Sir William Macpherson devoted most of his remarks to a
criticism of my statement that “ venereal diseases should never be lost sight of as a
war casualty,” and as I did not feel justified in taking up more time at the meeting*
I should now, with all due respect to his great experience, like to make a short reply
to his criticisms.

(1) Wherever men are congregated together away from their homes and female
relatives, as is the case in war, the tendency to indulge in promiscuous intercourse
when the opportunity arises, as during leave, is very much more evident than it is
under peace conditions.

(2) Lax morals are much more evident amongst women during a war than they
are in normal times of peace.

(3) Our troops do not normally serve in countries outside the Empire, except in
places like Egypt, where we have a responsible share in the government. It is only
during a war, or for some time after a war, and as a result of the war, that we keep
troops in places like Russia, Constantinople, Germany, &c., where the incidence of
venereal disease is very much higher than it normally is in peace time. Therefore
the argument that the incidence of venereal disease would be as high in these
countries under peace conditions as under war conditions does not arise.

(4) You cannot compare the incidence of venereal diseases in an army which
is largely composed of conscripts, many of whom are married men, with the incidence
of venereal diseases in our normal Army, which is a voluntary one, mostly composed
of single men.

(5) The incidence of venereal diseases during war increases directly with the length of
the war and the opportunities for short leave, and the increased prevalence of these
diseases was greatly exercising the minds of the Army authorities towards the end
of the late war.

(6) Unless the great importance of venereal disease as a war casualty is fully
recognized, suitable and sufficient hospital accommodation for the efficient treat¬
ment of these cases will not be available, and they will, perforce, have to be admitted
along with other sick and wounded to ordinary hospitals, which have no special
venereal disease department. This unfortunate state of affairs was very much in
evidence during the earlier stages of the late war.

i The following reply (inadvertently omitted at the meeting) should have been made to
remarks of Major Frost : “ Surgeon-Commander Hoyden, late of the Naval Service, has made
some experiments with a 4 chinosol and calomel cream ’ which will, it is hoped, be a considerable
protection against gonorrhoea as well as against syphilis. The difficulty is that the gonococcus is
probably implanted on the mucous membrane of the urethra at some distance from the
meatus.” — W. H.

Mar Section.

President—Sir John Goodwin, K.C.B., C.M.G., D.S.O., A.M.S.

Physical Training in the Army.
By Colonel R. C. Campbell, D.S.O.

(Inspector of Physical Training for the Army.)

(1) Importance of Physical Training.

Much ground is covered by physical training, but the following paper deals
only with the physical training of the soldier. In physical, as in any other
form of training, science and art must work hand in hand, for science keeps art
on the right lines and gives it that confidence which endows it with inspira¬
tion. I shall touch only on the more important aspects of the training from a
physical and psychological point of view.

(2) The Part taken by Training in War.

The wider the scope of the art of war, the more urgent is the need for study
and training for its successful application. As science depends on art for its
application, so does art depend on training.

Never in the history of warfare has training had so important or so
responsible a part to play in the conduct of war. The example and steadying
influence of veterans is no longer available for the inspiration and control of
the recruit in a battle. The toll of casualties and physical breakdown is too
great to allow a soldier, however staunch and stout-hearted, to be a veteran of
many fights.

Young soldiers, not old soldiers, therefore form the majority in a battle.
More than ever will victory depend on the efficiency of the training staff and on
its ability to fill the gaps of a battle with keen and well trained men direct
from the training areas. The overwhelming advantage in the future will lie with
the army which possesses the most virile system of training and can most
quickly replace casualties with well-trained men.

Ap—W 1

[December 11, 1922.

Campbell: Physical Training in the Army

(3) Effect of Scientific Progress on War.

What have we learned from the study of past wars? That with the
progress of science, war has advanced stage by stage from a series of tooth-and-
nail combats between selected champions lasting a few minutes, to a campaign
which directly involves millions, and to battles prolonged into months. We
have also learned that with the advance of science the more wholesale is the
destruction in war and the more harrowing is the strain on the human factor.
The defeat of an army is the collapse of its human factor under the strain
of war.

(4) The Human Factor in War.

What can we learn by looking into the future ? Very little. The progress
of science is so rapid that even now it would be extremely difficult to say what
weapons would be employed were a war to break out within a month. It
would be as absurd to prophesy what weapons would be used in a war waged
twenty years hence as to attempt to predict who would be the Prime Minister
when war was declared.

By a logical application of the lessons learned from past wars, we arrive at
a practical conclusion: that there is one never-varying factor on which all
training must be based, and that is the human factor. Both weapons and
methods may change, but the soldier always will be required to apply to his
use and contend against those future weapons and methods whatever they
may be. War will only end when the human factor can no longer bear the
strain.

(5) Preparation of the Human Factor.

The art of war, now more than ever, demands great intelligence and
character in the soldier to apply the inventions of science, and great physical
efficiency and character to withstand them. The demand will be increased
and not decreased in the future.

An army now is the manhood of the nation launched straight into battle
with very little technical preparation. The character and physical efficiency
of the army will depend on national education and training, the discussion of
which does not come within the scope of this paper.

The form of training which deals most directly with the human factor is
physical training. What time is there available in which to prepare soldiers
for the field ? In the last war it was about fourteen weeks. This greatly
limits the scope of physical training and confines it to two main functions:
(a) that of hardening and preparing a recruit for battle and (6) that of assisting
in the maintenance of the fighting efficiency of an army in the field.

(6) Grading the Human Factor.

Physical training could be of the greatest value not only in building up a
recruit to a requisite standard of physical efficiency, but in grading him as to
the type of fighting for which he would be best suited and then preparing for
the mode of fighting which he will carry out in the field.

Each arm requires a different type of man, in just the same manner as
each position on a football field requires a different type of player. It would

War Section

be absurd to jumble the players in a haphazard fashion. A good back may
make a poor forward and a useful forward a useless back. In the same way
a good infantryman, full of dash and devil, may be hopelessly wasted as an
artilleryman, and a cool, self-possessed gunner be a poor bayonet fighter. If
the best recruits are selected for the “ back ” line of an army and the infantry
gets the poorest typo of recruits, it will be only a matter of time before th©
best of these are killed off and the army loses its “ scoring ” power, in the
same way as a football team would lose it by deciding to sacrifice its forwards
for a good back line. The push and penetration of an army depend on its
infantry.

(7) Value of Grading.

The efficiency of an army would be greatly increased if recruits could be
graded and selected on the lines of a football or cricket team. By means of
physical training, recruits could be graded, not only as to their physical
efficiency, their strength and activity, but also as to their temperament, nerve
and endurance. They could be graded as to their personality and intelligence
by means of games and mental tests.

It would be of the greatest assistance to, say, an infantry commander if he
knew, on the arrival of a reinforcing draft, that each man would be labelled as
to his physical efficiency and temperament. He would know at once which
men were suited for the trench mortar section, which for the machine and
Lewis gun, and which best suited to use rifle, bomb and bayonet. By this
practical help he would be saved much time and disappointment and the hiatus
between training area and battlefield would be considerably lessened.

(8) Purpose of Physical Training.

Physical training in the army must be purposeful as well as constructional.
It must dovetail into, and be supplementary to, other forms of military
training. During physical training a recruit should perform exercises which
will make him better able to apply his technical weapons, and at the same
time imbue him with the spirit essential to the successful application of those
weapons. To illustrate what I mean, let us study the methods of a boxer
training for a contest. His forms of physical training are purposeful and do
more than make him merely physically fit. He does “road-work ” to develop
the endurance essential to a stubborn contest. He practises short sprints to
quicken his mind and increase his speed of thought as well as his quickness of
hitting. To introduce the spirit of the ring into his training he fights the sack.
He throws and dodges the “ medicine bag ” to improve his direction and
defence. In shadow fighting he stirs up and works upon his imagination and
develops his initiative. Every form of training he carries out is to a purpose,
which is physically and psychologically sound. So it must be with physical
training.

As the boxer associates the “ ring ” with all forms of training which he
practises, so must the battlefield be associated with the exercises performed
during physical training. For instance, exercises which require dash and
daring should be associated with the bayonet; those which teach a man
steadiness and control, with the firing of rifle, Lewis gun or machine gun,
exercises which require direction and development of the throwing muscles
with bombing, digging, carrying ammunition and wheeling guns with all

Campbell: Physical Training in the Army

heaving and leg exercises. Quickening exercises and games stimulate the
brain and improve alertness and quick resource in emergencies. Self-effort is
fostered by response to signals ; how to listen to and assimilate instruction, by
giving all explanations and words of command in a quiet and natural voice.
Physical training is complementary to the steady drill on the square. It supplies
the means of reaction after a period of sustained suppression. What is the
result of this ? There is a link and a mutual understanding between physical
training and other forms of training. Mutual support and the team spirit are
essential during training as they are during a battle. It is during training that
this team spirit is inculcated and the men are taught that one weapon it
dependent upon another.

Each squad, when it first parades for physical training, should be tested and
then graded according to its natural average physical, temperamental and mental
characteristics, and exercises should be selected which are most likely to raise
the squad to the required standard of efficiency.

The tables of exercises must be arranged to suit the temperament and
physique of the classes being trained. For squads in which most of the recruits
are slow-witted and ponderous, the exercises should be of a stimulating nature.
In the squads composed mostly of sharp-witted and highly strung city men they
should be of a restraining type and teach steadiness and self-control.

(9) Continuity of Physical Training.

It is absolutely essential that physical training must be continuous and be
kept up throughout the whole of a soldier’s service. To ensure this the
instruction of trained soldiers in physical training must not be confined to
experts. Every commander and leader should understand the value of physical
training and its practical application.

During peace training, soldiers should be classified annually as to their
physical efficiency, as they are in musketry. For trained soldiers physical
training should include such pastimes as boxing, wrestling, swimming, obstacle
training, gymnastics and some practical team game such as basket ball. All
of these have a direct military value but require careful instruction when
taught to beginners.

(10) Physical Training and Convalescents.

Equally important and valuable work can be done by means of physical
training in salvaging convalescents. The morale of a man from hospital is
generally sub-normal. While a patient in hospital he is treated with every
care, everything is done for him, his life is effortless so far as he is concerned.
He is soft, morally and mentally, as well as physically. He requires special
care before he returns to his unit. His will, as well as his body, must be
strengthened. His training should be attractive and gradual. His physical
training should commence with games and quickening exercises, which create
an interest and stimulate self-effort. From these the training should progress
towards exercises of self-control and sustained effort and the more strenuous
British games and sports.

Although physical training is a sympathetic link between the hospital and
the battlefield, yet it must be in no way associated with the hospital and looked
upon as a remedial form of training, or the spirit of the training would be

War Section

killed. It would be as demoralizing to associate the gymnasium with the
hospital, as it would be to associate the hospital with the cemetery. Physical
training in the army is a creative training which deals with a man who is
passed as organically sound. It is on this hypothesis that it is based and
carried out.

(11) Physical Training in Peace and War.

In peace, the physical training of a recruit coincides with other forms of
training in the depot and lasts about sixteen weeks; the course will consist
of eight tables or series of exercises. The tables are progressively arranged, the
progress being more gradual in the early tables than the later ones.

In order to arrive at concrete results and see monthly the effects of the
training, practical physical training tests are being carried out with recruits in
all commands. The charts I have brought show the results of the tests which
were carried out during October and November, during which time over 11,000
recruits were tested.

In the event of war, the same tables would be employed, the only difference
being that no exercises which require apparatus would be used. War training
will be peace training shorn of its adornments; this will enable the recruit’s
course of training to be completed in about twelve weeks instead of sixteen,
and to be carried out in any training centre.

(12) Physical Training and Mobilization.

During the first few weeks of mobilization, the training camps are deluged
with enthusiasts, eager for battle, and so unused to restraint or military
discipline that it is practically impossible to carry out any form of technical
training. Instructors are scarce, weapons and uniform are not available, the
small and harassed staff experiences a most difficult and trying time. It is
during this period that physical training can be most helpful, as it is a
sympathetic form of training understood alike by civilians and soldiers. No
arms, apparatus or uniform are needed. It can be made the means of
organizing a mass into military formation, accustoming it to restraint and
discipline and inculcating soldierly thought and ideas. It is a most useful
leading rein from civilian life into the army.

(13) Imperative need of larger Physical Training Staff.

On mobilization, the physical training staff will be increased to cope with
the influx of recruits: it is for this purpose that physical training staff reserve
is required.

The situation will be considerably helped by having a physical training
staff instructor attached to the permanent staff of each Territorial Force unit,
and a non-commissioned officer trained as an assistant instructor during
peace for each company, or its equivalent, in the Territorial Force.

The establishment of the physical training staff at the end of the last war
was 2,200, or more than twenty times the strength required for the training
of the army during peace.

Campbell: Physical Training in the Army

(14) Creation of Physical Training Instructors.

The training of assistant and staff instructors is centred at the Army
School of Physical Training at Aldershot.

The assistant instructors are selected from the N.C.O.’s who reach a high
standard of physical efficiency during their recruit’s course of physical
training and who have continued to show aptitude for the work. These
selected N.C.O.’s undergo a short preliminary course in their commands before
assembling at the Army School of Physical Training.

The preliminary courses, besides preparing the N.C.O.’s for the longer and
more strenuous course at Aldershot, also act as a sieve by means of which
those not likely to make efficient instructors are eliminated. The N.C.O.’s
who qualify at Aldershot return to their units and are employed under staff
instructors training recruits. During this probationary period they are closely
supervised and helped by the staff instructors. When proficient as trainers
the second portion of their certificate is endorsed. They then become fully
qualified assistant instructors and gain the distinction of wearing the “ crossed
swords ” on the right arm.

Those assistant instructors, who show special keenness for the work and
prove that they have character and the knack of being able to impart
instruction, are selected to go through an advanced course of physical training.
At this course, in addition to physical training, subjects of a recreational
nature are included in the syllabus, so that when the N.C.O. returns to his
unit he is able to assist in the organization of games and sports and is capable
of training the regimental officers and N.C.O.’s to become instructors in the
trained soldiers’ physical training exercises.

As the chief duty is to train and teach teachers, the physical training staff
is selected only from those who have passed through and attained a high
degree of proficiency in the advanced course. The greatest care is taken in
the selection of the staff, only those of the highest integrity, as well as of the
highest proficiency, being considered.

To train and supply a sufficient number of physical training instructors for
units during war, there should be a school in each command to train assistant
instructors, while the Army School of Physical Training should be used solely
for training staff instructors for all the Forces of the Empire.

(15) The Co-operation with Civil Boards and Associations.

Physical training staff instructors during war would be recruited from the
teachers of physical training trained by the Board of Education and from
athletes of prestige and personality. The majority of the excellent physical
training staff instructors during the last war were obtained from this source.
For this reason alone the army physical training staff should work in
sympathy with, and keep in the closest touch with, the Board of Education and
the different amateur sports and games associations. One means of realizing
these aims would consist in having a universal system of physical training
throughout the Empire. The Army is about to adopt the Board of Education
terminology in physical training, and it is hoped that the Dominions will do
likewise. The advantages of having one system of physical training through¬
out the Empire are many and far-reaching, both from an Imperial and from a
training point of view.

War Section

The physical training staffs of the Royal Navy and Army work together in
the closest co* operation. Officers from one Service undergo courses held by
the other Service. An interchange of lecturers is arranged and technical
points are brought up and discussed at joint conference. This unity and
interchange of ideas in a common cause has been of great assistance to the
army, and has done much to stimulate progress in physical training ; and it is
a policy which should be extended to include the whole Empire.

DISCUSSION.

Surgeon Captain A. Gaskell, R.N., asked three questions: The first and most
important was: How could the curse of charlatanism be removed from everything
connected with physical training ? The science was one on which every Tom, Dick or
Harry felt competent to speak and it was common knowledge that many people took
it up simply because it proved easy and lucrative. Just as horse-racing was said to
pollute the honour of every one who touched it, so physical training seemed in danger
of corrupting many otherwise honest men. Logically the foundation of physical
training was physiology and to physiologists they should turn for instructions,
but medical men should be continually supervising, lest any irregularity crept in.
The athletic medical man was the right person to direct physical training, but even
he must be watched lest he take up this deplorable charlatan clap-trap. He
(Surgeon Captain Gaskell) referred to an article which appeared in the Blue Book.
“ The Health of the Navy for 1905.” The second question was: Had any method been
devised for estimating the amount of “guts” in a recruit? Physical measurements
were all very well but the Great War had shown us that fine physique was not
necessarily a token that a man would “ stick out ” all sorts of privations and dangers.
The third question was: Had any new tests been devised for recruits on the lines of
those introduced by the Air Force ? These tests had been introduced to discover the
men whose nervous equilibrium might be so unstable as to lead to accidents. Thus
these men could be invalided before the accidents instead of afterwards. ■

Surgeon Commander K. DlGBY Bell, R.N. (of the Royal Naval School of Physical
Training) pointed out what a unique situation this was for medical officers of the War
Section of this Society to be addressed on a subject, which was, after all, a branch
of preventive medicine, by a Colonel with no medical training. They were indeed
fortunate to have had this opportunity, and of hearing in particular of the good work
carried on at the headquarters of physical training in the Army. Colonel Campbell had
dealt with his subject almost too briefly, but yet, what he had told them was full of
lessons for them all. Colonel Campbell had explained the continuity of the training
which was conducted in the Army—a state of affairs for which those in the physical
training branch of the Navy envied. Continuity in teaching and of work at
training establishments was the essential factor for obtaining satisfactory results, and
with the practice of changing round appointments every two years or so, as carried out
in the physical training branch of the Navy, this continuity was handicapped very
seriously. He (Dr. Digby Bell) drew special attention to another remark made by the
lecturer: that physical training was a sympathetic link between the Services. The
truth of this had been fully realized at the Royal Naval School of Physical Training.
Physical training went far further—it was a sympathetic link between the Mother
Country and the Colonies (who met on a common ground in all sports and recreations) ;
it was a very real sympathetic link between all physical trainers and the medical
profession (who met each other on the common ground of public health and eugenics).
Indeed—as had been so often pointed out—if the whole subject of physical training
could only be governed and protected by a properly appointed Central Board of Control,
like the medical profession had to-day, it would be of vast benefit to the health and

Campbell: Physical Training in the Army

morale of the whole nation. When degrees for the practice of physical training were
granted by Universities on the same lines as medical degrees, then no doubt the taint
of charlatanism, to which Surgeon Captain Gaskell had just drawn attention, could
no longer be associated with this noble profession.

Lieutenant-Colonel Boylan Smith stated that he had had difficulty in getting
physical training instructors to take interest in the physical training of men in a
convalescent depot in France who were suffering from slight disabilities, but who were
well able to undergo a graduated course of exercises, though unfit for the strenuous full
course. He believed that the need for training such men would always arise in any
war in which convalescent depots operated as they did in the late war. These men
were not disabled enough for orthopaedic hospitals and they were too fit to remain in
general hospitals. Although they were expected to pass out of convalescent depots
to their reinforcement camps as fit fighting men, the physical training instructors in
many cases were uninterested in their physical development. The minds of the
physical training instructors should be disabused of the notion that these were
“ medical cases.” Lastly, how did Colonel Campbell account for the rise in* fficiency
immediately succeeding the drop shown on all the wall charts exhibited ?

Lieutenant-Colonel P. H. Henderson said that he would touch upon two points in
the discussion : First, he cordially welcomed Colonel Campbell’s announcement that
the Board of Education was about to introduce a universal system of physical training
for boys throughout the United Kingdom, that the system of training in the Army
would be identical with that of the Board of Education, and that there was a hope that
this system might soon become universal throughout the Empire. It w r as obvious
that such a training would greatly increase the physical capacity of the nation, and the
benefit to the Empire would be inestimable. This training should be particularly
valuable in assisting recruiting officers to obtain suitable recruits for the Army.
Most of them knew how difficult it was at the present time to get suitable recruits.
Large numbers were now rejected because they were not up to the standards considered
necessary for the Army; others, in considerable numbers, who were passed fit had
subsequently to be discharged because, under training, they failed to acquire the
physical capacity necessary for the Army. This was not only bad for the Army
but bad for the taxpayer. After a considerable experience he could not help thinking
that the present standards adopted for recruits were not altogether satisfactory and his
suggestion was that if on leaving school the physical and mental capacity of every boy
were to be recorded on an index card in a way similar to that in which the condition
of his organs, teeth, &c., were recorded on his health index cards, it would be of the
greatest assistance to recruiting officers and medical examiners of recruits in selecting
men for the Army. Convenient formulae for recording the physical and mental
capacity could easily be devised and he (Colonel Henderson) hoped Colonel Campbell
would use his influence in order to have a satisfactory system universally introduced.

His second point had reference to the peculiar dull white complexion which was
such a common characteristic of highly trained instructors of the physical training staff.
Had any physiologist ever satisfactorily explained the cause of this peculiar pallor?
Colonel Campbell thought it was due to the indoor nature of their employment, but this
explanation hardly satisfied him (Colonel Henderson). Their pallor was quite different
from the anaemic complexion associated with certain factory workers and others who
spent long hours indoors in unhealthy atmospheres. Highly trained long distance
runners and boxers who might do most of their training out of doors also developed the
same peculiar pallor and he (Colonel Henderson) suggested that it was possibly
associated with some alteration in the heart and blood-vessels but he did not suggest
that the condition was necessarily an injurious one.

Air-Commodore D. Munro, C.I.E., referred to Colonel Campbell’s plea that
physical training should be largely in the hands of physiologists; he stated that in the

War Section

Royal Air Force they had successfully applied to the control and assessment of
results of physical training certain physiological tests which had been initially designed
for the determination of physical fitness for flying duties in officers ; that these tests
had been applied both before and after a course of physical training and that, at the
latter stage, they accurately recorded the resulting degree of improvement in physique.
He felt that on the grounds of co-operation towards a standardized system of physical
training throughout the Empire, as proposed by the author of the paper and subsequent
speakers, there was ample indication that these Royal Air Force tests could be
introduced into the scheme with considerable benefit as a scientific method of recording
the results of training and the standard of physical fitness of individuals at any given
moment.

Colonel C. H. MELVILLE asked if it might not be possible to increase the number
of hours given to physical training to two per day during the first month of training of
recruits. Physical training was much liked by the recruits and the more they had
of it and the less of barrack-square drill, the more gradual and pleasant was the
change from civil to military life. He asked whether the supply of gymnasium kit
could not be made a legular issue. It would be of great assistance in ensuring cleanly
habits. It was impossible for a man to work well in serge clothing.

Major N. V. Lothian, M.C., bore testimony to the very great value of the
existing method of physical training, as outlined so clearly by Colonel Campbell,
and stated that as a medical officer, and one who had had the good fortune to pass
through the Instructor’s Course at the Central Gymnasium, he fully supported Colonel
Campbell’s claims, not merely as to the physical results of the existing system, but
also as to the associated effects on the psyche. He would raise a question however on
one point to which Colonel Campbell had referred, namely, the need for continuity in
training. It seemed that some better organization was required to ensure continuity
of physical training among trained soldiers. The subject was sufficiently safeguarded
while the soldier was a recruit, and afterwards to some extent also while he was in his
depot; but once he was posted to his unit, it w r as very questionable if he got sufficient
physical training to maintain those qualities of speed and agility, quick response and
endurance which, as a six months’ recruit, he undoubtedly acquired. Many regimental
personnel—and a large proportion of non-regimental personnel in administrative corps
—never did any more physical training after leaving their depot. The physical con¬
dition of such men, more especially the clerks, cooks, and storemen, could hardly be
perfectly fit on mobilization ; yet all had to march together. The retreat from Mons
—very marvellous effort as it was, averaging some 16 miles per day—showed how,
despite the best will in the world, and even allowing for the inevitable dilution with
reservists, a proportion of casualties occurred through men falling out physically
exhausted and unable to struggle further. It would appear that the condition of
troops, who might at any time have to take the field, might well be improved as a whole
if physical training were continued throughout a man’s service. The question of
reservists was, of course, a larger issue.

Lieutenant-Colonel C. R. SYLVESTER BRADLEY said that, speaking as a medical
officer, interested more particularly in the physique and training of the recruit, there
were one or two questions on which he would be glad if Colonel Campbell would give
him the benefit of his experience. His first question dealt with physical standards.
He stated that the physical standards for the recruit on enlistment were fixed pre¬
sumably with the view to providing, among other things, the most suitable material
from which to build the trained soldier; but had they any facts that would justify the
assumption that physical capacity (in other w'ords the capacity of the individual to
perform a definite amount of work) could be correlated to physique ? Had Colonel
Campbell any information as to the physical capacity of the average untrained recruit
to run a hundred yards, or to high jump for instance ? To what extent was this capacity

40 Campbell: Physical Training in the Army

improved by physical training, and could this capacity be shown to be related to
physique ?

Another question he w’ould ask Colonel Campbell referred to the psychological
aspect of physical training. The number of recruits who were discharged from the
Army for defective intelligence whilst at their training was so large that some effort
was needed to eliminate these ineffectives either on enlistment or before any large
amount of money had been expended on their training. The ideal arrangement would
be for all recruits to be mentally tested by some approved method before enlistment,
but the obstacles to such a course were very great, not one of the least being the
lack of trained personnel to carry out these tests; and it had occurred to him that the
solution of the question could be found, if the estimation of a recruit’s mental capacity
were carried out on his arrival at the depot by the physical training staff, in con¬
junction with the educational and medical branches, some modification of the
Binet-Simon method being used. A short time ago, some initial experiments on
these lines had been carried out under his direction, and the results were most
encouraging, and would appear to justify further investigation.

His last question referred to the remedial si(Je of physical training. His experience
had been that Army physical training instructors were rather inclined to look upon
physical training solely as a means of developing the “ fit ” to the exclusion of the
unfit: but he would point out that no man was perfect, either morally, mentally or
physically. Fitness was only a matter of degree, and remedial exercises for such
minor defects as slight flat-feet, scoliosis, deficient chest excursion, &c., were
worthy of more care and attention than they were receiving at the present time.

Colonel R. C. CAMPBELL (in reply) :—

(I) To Surgeon Captain GankeU, B.N.

(1) Charlatanism, without a doubt, often is associated with physical training, but it
is generally in connexion with its medical or curative side. Professional strong men and
others advertise extravagant claims as to the number of diseases they can cure, and
working upon the minds of the hypochondriacal, carry on a lucrative business. On the
other hand they may do some amount of good if only they can stimulate their flabby-
minded patients to carry out any form of exercise which requires self-effort and per¬
severance. The physical training earned out in the Services is based on the Swedish
system—a system which has been in vogue for over a hundred years, and has been
proved scientifically to be sound and without the slightest inherent taint of charlatanism.
If the principles of this system of physical training are observed there is small danger
of any harmful irregularity creeping in. There is a medical officer “ hygiene specialist*’
on the staff of the Army School of Physical Training. His knowledge is most helpful
in testing scientifically what had often to be tested empirically with much labour and
loss of time.

(2) Those in charge of physical training should have a sound knowledge of physi¬
ology, they should be athletic and have a practical knowledge of the work, but, more
important still, they should possess a full appreciation of the psychological aspects of
physical training. The chief value of any training is psychological, and in no training
does this apply more forcibly than in physical training. The goal is the mind, which
must be reached by means of the body. Every physical expression has a psychic
equivalent, the mind is the creative and dynamic force w r hich inspires and compels all
the movements of the body. The character and mentality of the recruit is shown in
the manner in which he performs his exercises. Physical training is subjective, not
objective, as in drill, during which movements are often performed subconsciously. An
instructor may be a renowned athlete and have a thorough knowledge of physiology, but
unless he has force of character and personality behind his prestige and knowledge he
will never reach the goal to which he is striving—the mind and soul of the recruit. An
instructor without character will, in a very short time, be appraised by a class of

War Section

recruits. He will be found to be a sham. To my mind, he is the real charlatan in
physical training.

(8) Tests are carried out with recruits in the Army; they include tests of endurance,
speed, strength, agility, dash and control. I trust these will be found to have a practical
value, and be suitable and helpful to the Army as the tests of nervous equilibrium are
to the Air Force.

(II) To Lieutenant-Colonel Baylan Smith.

(1) Physical training instructors should certainly take an interest in and be able to
train all types of men at convalescent depots. All convalescents should be graded
according to their physical fitness, whether they are normal or subnormal. Those who
are normal and suffering from minor disabilities should be classed together and given
suitable graduated exercises and games. With the subnormal the training should
progress towards the normal as the disabilities disappear. It is by mixing fit men with
men who are not fit that the latter get neglected and become disheartened. The first
day a recruit attends for physical training his natural abilities and peculiarities are
studied in a series of tests and noted down in the instructor’s squad book. These
observations, together with those of the medical officer, diagnose fairly accurately the
mental, temperamental, and physical condition of each recruit. This method of
studying each recruit before commencing his physical training would also apply to
the physical training of convalescents, who could be diagnosed and classified, and be
given graded exercises according to their classification. I was fortunate enough to
see the physical training energetically carried out at the convalescent depot in
question, when it was under both Colonel Cowey and Colonel Boylan Smith.

(2) As yet it is difficult to account for the rise after the fall, shown on the charts.
I think that the fall was due to recruits having been taken for musketry during
their physical training course, and the rise was the result of the resumption after the
hiatus.

(Ill) To Lieutenant-Colonel Henderson.

(1) The Army has decided to come into line with the Board of Education, and to
adopt its terminology, and as the Army caters for recruits and soldiers from the
age of 18 upwards, it is hoped that by this means the recruit will find in physical
training a sympathetic link between his youthful life and his training in the Army. If
the scheme can be extended throughout the Empire a bond will be formed which will
help to keep all the Dominions in sympathetic touch with the Mother Country and with
one another.

(2) I agree with Colonel Henderson that it would be an excellent thing if at
school boys and girls had to pass standards of physical efficiency as well as educa¬
tional standards. A boy who achieves Standard YII in education, but is only Standard
I physically, is a greater menace to the State than a boy who is Standard I in education
but Standard VII physically. Such a scheme would have a far-reaching effect on the
the national health and life generally, and be of the greatest national value, not to
mention the assistance it would be to the Services in grading and classifying
recruits.

(8) With regard to the peculiar dull-white complexion of staff instructors. I had
put it down to the fact that practically all their work is carried out indoors. In France,
where the work was carried out in the open air, the instructors were bronzed and sun¬
burnt. Our war diarist in France, in August, 1918, writing of the outdoor training,
said : u From the same cause (the sunshine) the instructors turned nearly black, and
were hardly distinguishable from the brown-skinned coolies who at times were employed
in constructional work about the camp and assault course.” The ultimate effect is

illustrated by the aspect of a healthy old gentleman of 79 years—Major J. C-,

—who may be seen daily taking long walks around Aldershot. He is ruddy of face and
bright of eye. Back in the sixties he was the first Sergeant-Major of the Army

Campbell: Physical Training in the Army

Gymnastic Staff. The clear eye and the general mien of the staff instructors, proves,
whatever their pallor, that they are fit and in hard condition. I had never associated
the white skin w r ith any alteration in the blood-pressure.

(IV) To Commodore Munro.

In my paper I advocated the assistance and co-operation of the physiologist, but
the point 1 wanted to make was that the chief factor in determining the purpose of the
training was psychological. Each Service requires a different type of man, and a
different type of training. A Bugby footballer forward requires different training from
a boxer. Individual boxers themselves differ, and require different handling. Methods
suitable for a hulking ponderous heavy-weight would not be suitable for a “ live-wire ”
bantam-weight. The anatomy of Joe Beckett is the same as that of Jimmy Wilde;
but the character and temperament of each are completely different. The successful
trainer is the one who can understand the psychological aspect of his form of training
and apply it to the mind of the man he is training. It would be of the greatest interest
to know how the Romans trained their recruits, most of whom, even when Rome was
at the height of her power, must have come from the slums of her cities. The campaigns
which they succeeded in accomplishing called for the severest tests of endurance and
physical hardihood. The knowledge of physiology in the times of the Romans was
very elementary. To make up for this they must have been wonderful psychologists,
if I may be permitted to use this term. I agree with Commodore Munro that it would
be of the greatest assistance if there were a close co-operation between the Services, and
if the tests carried out by each Service were passed round to the others, with a view to
establishing a standardized system of training and tests for the forces of the
Empire.

(V) To Colonel Melville .

(1) An hour a day for five days in the week is sufficient time for the physical
training of a recruit now that he has an increased number of subjects to learn. A
recruit’s syllabus of training should be so co-ordinated that one form of training reacts
on and assists another. For example, I consider that physical training is the natural
reaction to drill on the square and that one helps the other.

(2) Steady drill on the square is essential, to instil into the recruit the unhesitating
obedience to orders, and the habit of working with his comrades, which are the basic
qualities in a soldier. I agree that the first month on the square is extremely tiring
and a great strain upon the nervous system of a recruit, but to what extent this train¬
ing can be lessened it would be hard to say. I would not advocate more physical
training.

(3) Shorts and vests are now worn by all recruits during physical training. At
some depots, recruits bring towels to the gymnasium and have a rub down after work.
In suitable weather I advocate that recruits should do their training stripped to the
waist, and allow the sun and air to act upon their skin. This, together with the rub
down after their work, would have a healthful and stimulating action upon their skin.
Nothing can be more insanitary and contrary to all principles of hygiene than to allow
soldiers to wear the same thick underclothing, often sweat-laden, day and night for a
week without changing. It is a great blessing that recruits do change their clothes at
least once a day, if only for an hour, during physical training. Perhaps in time some
form of sleeping suit will be provided for the soldier. I believe we have to thank
Colonel Melville for being one of the pioneers who obtained suitable kit for recruits in
which to do their physical training.

(VI) To Major Lothian .

(1) I agree that it is essential to have continuity in physical training. The importance
of this is realized by many units which carry out physical training daily under regimental
arrangements. I trust it will be only a matter of time for all soldiers to be classified
annually according to their physical efficiency, as they are in musketry. Suc-h a

War Section

regulation would ensure that clerks, cooks and storemen, passed a standard of fitness
at least once a year.

(2) The stifling weather and heavy packs, together with the trying nature of the
whole situation, I consider were the reasons why so many fell out during the retreat
from Mons. The reservists were soft, especially their feet, which could not bear the
added weight of the pack. This was specially noticeable when marching along pave
roads.

(3) I agree, again, that a fighting force should be kept fighting fit. There is a great
danger of judging the efficiency of an army by its man power, instead of by its fighting
power.

(VII) To Lieutenant-Colonel Sylvester-Bradley.

(1) Every recruit, when he first parades for physical training, is tested by means of
natural activities as to his agility, strength, control, and intelligence, in order to gauge
his natural abilities. His first field test is carried out after he has completed about
twenty attendances and it is continued monthly until he completes his course of
physical training. The tests are still in the experimental stage, but they include tests
of speed, endurance, agility, dash, control and strength. The record of these tests
was only commenced in October, 1922. Up to now 11,000 recruits have been tested and
the results recorded in the form of graphs as shown to the meeting. By means of these
tests we hope to follow the improvement, or any fluctuations, during the course of
physical training. Tests are also a concrete means of letting a recruit observe the
value of the training and the results of his efforts.

(2) I quite agree that all recruits should be tested mentally, but I suggest that the
tests should be carried out by the Educational Corps which gets recruits daily while
they are at the depot.

(3) All observations made by the medical officer are noted in the instructor’s squad
book. It is found that most of the minor defects automatically correct themselves
without any special treatment. There are cases which require special treatment, but
during my four years as Superintendent of Physical Training in the Southern Command,
these were extremely few. As a rule, slight 44 flat ” foot is caused by weak supporting
ankle muscles. These become strengthened as the training advances. Scoliosis, when
caused by one leg being shorter than the other, or by a defective pelvis, is difficult to
correct by means of the ordinary exercises, but scoliosis, when merely the result of
one-sided vocational occupation becomes automatically righted in a very short time.
Work in the open air, regular meals and exercise increase the size and movement of
the chest by natural means. The unfit in a class should receive special care and such
encouragement as will induce them to attend voluntary work in the evenings (at which
an instructor is always present) and be shown special exercises which they can carry
out 44 on their own.” I found this system better than grouping the defectives and
giving them special exercises, the moral effect of which is not good and more than
counterbalances the physical benefit derived from the exercises. All recruits should
pass the 44 standard ” test by the time they complete their physical training. The
names of those who fail to do this are submitted to the superintendent of physical
training of the command. This, I hope, will ensure that no weak and unfit recruit is
allowed to slip through the 44 mesh” of physical training. In connexion with the
treatment of recruits who are suffering from slight defects we get the willing support
and able assistance of medical officers at depots.

Venereal Disease as a War Casualty

Venereal Disease as a War Casualty.

CORRIGENDUM.

In the discussion on Surgeon Hear-Admiral Bett’s paper on “ Venereal
Disease as a War Casualty,” published in the February number of the
Proceedings , an addendum by Lieutenant-Colonel Henderson appeared, 1
criticizing the remarks made by Sir William Macpherson during the discussion.
It is only fair to Sir William Macpherson, therefore, to note in reply that his
remarks were intended solely to support Admiral Bett’s view that venereal
disease could not be regarded as a war casualty, and that any exaggeration of
the “ war casualty ” point of view, so strongly urged by Colonel Henderson,
diminished the importance of dealing with venereal disease in time of peace. It
was, therefore, with the object of urging the need of combating venereal disease
in time of peace, and regarding it as a peace casualty more than as a war
casualty, that Sir William Macpherson’s remarks were made, and in making
them he could not avoid referring to Colonel Henderson’s statements, which
had been made just before he rose to speak and which were opposed to the
views that venereal disease was not necessarily or specially a war casualty.

i Proceedings , 1922-23, xvi (War Sect.), p. 29.

Mar Section.

President—Sir John Goodwin, K.C.B., C.M.G., D.S.O., A.M.S.

The Effect of Tropical Climate on Physical and Mental

Efficiency.

By Squadron-Leader T. S. Rippon, R.A.F. Medical Service.

(I) Preliminary Investigations into Visual Fatigue in India.

DURING the course of my first year’s work in India, I noticed that there
was a tendency for pilots, who, in Europe, had not had any ^difficulty in this
respect, to make bumpy landings. Moreover, when tested with the “ orthotele¬
meter” they showed evidence of a lowered degree of binocular stereoscopic
vision, and with Bishop Harman’s diaphragm test, they showed a wider
“ ocular poise,” indicating inability to maintain an even ocular muscle balance,
which they did not show in England.

I inferred that these signs pointed to some degree of visual fatigue, and in
October, 1920, I discussed the question with Flight-Lieutenant P. C.
Livingston, R.A.F.M.S., who was in medical charge at Ambala, and found
that he had noticed similar results. We then agreed to work together, and all
officers and men who came to him complaining of discomfort due to glare
were taken to the Medical Research Laboratory, and we examined them
together. The following examples are briefly recorded:—

Case I.—Flying-Officer W., aged 27. Hours flying 450. Iris blue. Vision : Right,
2 ; left, 3. Two diopters of manifest facultative hypermetropia. Conjunctive healthy.
States that he has a tendency to ” flatten out ” too soon, which he puts down to glare.
He was not sure where the ground was, so he flattened out early to avoid flying into the
ground. In March, his eyesight was normal, but later, as the discomfort from the
glare got worse, his landings deteriorated. He suffered from headaches and aching
eyes. He had to blink and to strain in order to see objects.

Case II.—A.C. 2 E., aged 21, mechanical transport driver. Complains of frontal
headaches whilst driving in the sun. After he returns from duty he has difficulty in
reading, and says ‘‘ the print looks out of focus,” and a headache follows. At these
times his eyes water. Has photophobia but no conjunctivitis. Cannot see as clearly
at night as in England, a most important symptom, and had an accident last year
whilst driving a car at night, when he failed to perceive the road whilst turning a comer
and ran through a fence.

Case III.—A.C. 2 W., aged 20. Complains of dimness of vision after reading and
writing which has come on since arrival in India. Dull pain over eyes.

Case IV.—L.A.C M., aged 26, mechanical transport driver. “Used to drive in
France without lights, but cannot do so in India as he cannot see the road.” (This
came on after six months residence in the country.)

Case V.—A.C./l S., aged 20. Complains that three months ago pain began in back
of eyes and frontal area. When reading, the letters often get blurred and run into

Au—W 1 April 9, 1923.

46 Rippon: Effect of Tropical Climate on Efficiency

each other. When facing the glare everything he sees becomes blurred, but his vision
improves within about half a minute. Sees yellow dots floating before his eyes.

During April we examined thirteen cases of discomfort due to glare, and
twelve cases during May and June.

Symptoms.

Inspection of the symptoms of which the patients complained showed that
they could be roughly classified into three groups :—

(1) Superficial Imitative Group .—The most prominent symptoms were
conjunctivitis, blepharitis, lacrymation and frontal headache.

(2) Retinal Fatigue Group. —Symptoms of dimness of vision at night or
dusk, prolonged after-images and slow adaptation.

(3) Lastly we have cases in which the patient complains of inability to
sustain accommodative efforts or convergence for near objects for any length
of time. Lacrymation, headache, mental fatigue and frowning are noticed.

These cases form the majority of the subjects who complained of glare.
They are very similar to those cases described by Donders as asthenopia, in
his report on “ Anomalies of Accommodation and Refraction,” issued by the
Sydenham Society, in 1864.

Accommodative Asthenopia.

To the best of my knowledge it was Donders [1] who first described
asthenopia in detail, as follows: He said that though the power of vision in
those affected with asthenopia was usually acute, nevertheless during reading
or writing or other close application of the eyes in indistinct light, objects
became blurred or confused and a feeling of fatigue and tension came on, in and
above the eyes.

Cause. —Donders believed the cause to be a moderate degree of hyper-
metropia. The exciting circumstance, however, should not be confounded with
the cause, and the exciting condition for the occurrence of asthenopia was the
presence of insufficient range of accommodation.

Lieutenant-Colonel Maynard, I.M.S., late Ophthalmic Surgeon to Calcutta
Medical College, in his “ Manual of Ophthalmic Practice ” [2], states that accom¬
modative insufficiency is very common in the tropics, where the climate of the
plains is so enervating. He considers it to be due to weakness of the ciliary
muscle, and states that it is preceded by illness, all the toxic conditions,
neurasthenia, and so on.

Investigations of Amplitude of Accommodation in cases complaining

of effects of Glare.

(1) Definition of Amplitude of Accommodation. —The quantity of accom¬
modation possessed is termed the amplitude. It is the dynamic force necessary
to convert the eye from the refractive condition at the far point to that
required for vision at the near point. The far point is the most distant point
at which clear vision is possible, and in emmetropia is at infinity. The near
point is the nearest point at which clear vision is possible. If the emmetrope
reads clearly at 10 cm. we know that he must be exerting 100/10 diopters
of accommodation (10 diopters =-• the amplitude). Fine print, or a coarse hair
on a white background, is approached towards the eye, and the nearest point

War Section

at which it is seen clearly is measured. Owing to changes in the lens, the
near point recedes as we grow older, and the amplitude at thirty years is about
half what it was at the tenth year. The curve of amplitude worked out by
Donders is still found in all text-books of physiology and ophthalmology and
is the one we used as the standard in our investigations.

(2) Method of estimating Amplitude of Accommodation by the Optometer .—
After experimenting with various types of optometers we settled on the
“ orthops ” pointer, which is described in “Visual Optics” by Lawrence [6].
This consists of a flat wooden bar scaled in centimetres and diopters showing the
corresponding age opposite each figure, and with a sliding carrier which holds
a card with printed words which is used to focus on.

We estimated the refraction subjectively and allowed for any myopia or
apparent hypermetropia. Then the closest point of distinct vision was obtained
by running the carrier near to the eye until the print became blurred, and then
slowly moving it away until it became quite clear and sharp. The examiner
covers one eye with a card, and tests each eye separately.

Results.

The results of our investigations into the association between insufficient
“ range of accommodation ” (as Donders puts it) and asthenopia is shown in
the attached diagrams.

Series 1 (glare cases), fig. 1.—Shows twelve cases complaining of symptoms
due to glare. The vertical figures on the left indicate the amplitude of accom¬
modation in diopters—and the curve represents Donders' figures and shows
the average power of accommodation at different ages. In Series 1 there were
twelve cases, each eye was tested separately and plotted on the graph on the
line corresponding to the correct age. By comparing the distance of the dots
from the normal curve of Donders, we see the amount of the insufficiency of
accommodation. Thus we notice in the first series, that twenty-two out
of twenty-four tests are below the curve.

In Series 2 (glare cases) (fig. 2), twenty-three out of twenty-four dots are below
the curve and the bulk of the dots indicates a slightly greater insufficiency than
Series 1, which was taken a month before. These cases were not suffering
from any disease, or the effects of any disease which might have caused a
general loss of tone and consequent deterioration of the ciliary muscle. The
only condition found by Flight-Lieutenant Livingston and myself was that
of “ effects of glare.” The number of cases examined is not enough, for us
to venture to state any figure indicating the percentage of fatigue of the power
of accommodation, but if we were to draw a circle round the largest group in
each series, the centre of the circle would give us a figure, indicating that the
power of accommodation was about half what it ought to be. My own practice
is to grade cases as “ marked fatigue ” when the amplitude is 30 per cent, less
than normal.

The Control Series (1 and 2) consisted of all the officers available on the
station. There was no selection of any kind. All had been exposed to glare
for an average of nineteen months. None of them had complained of glare
sufficiently to apply for medical relief, but when asked if they had noticed dis¬
comfort from glare there were four individuals in Series 1 and two in Series 2
who replied in the affirmative. Inspection of the results shows that the eye
condition of the controls varied considerably, and so the result was a purely
negative one, though very useful. Thus we notice that whilst the controls are

48 Rippon: Effect of Tropical Climate on Efficiency

roughly grouped round the normal curve, there are some individuals who are
above normal and others below. The four persons who complained of symptoms
of glare were all suffering from marked fatigue of accommodation. Working
out the degree of insufficiency of accommodation in percentage gave a rough

idea of the difference between the controls and the cases suffering from glare.
It must be stated that these figures cannot be taken as indicating the relative
proportion of fatigue due to glare with any amount of accuracy, on account of
the small numbers examined.

War Section

Accommodative Asthenopia in Egypt.

On arrival in Egypt I visited each station and carried out routine examin¬
ations of all available flying personnel. An attempt was made to find out
whether there was any correlation between accommodative asthenopia
(estimated by receding of the near point) and length of service in the East:
115 examinations were made and the results indicated that there is a con¬
stantly increasing asthenopia in most individuals during their residence in Egypt
and the East. The subjects with marked defects of power of accommodation
usually had a history of erratic landings.

The diagram exhibited shows the results of an examination of sixteen
officers at Ramleh, and indicates that some pilots develop accommodative
asthenopia which varies in degrees of severity according to the length of their
stay in the East. Certain individuals, however, do not show any correlation.
These cases were found to have a special predisposition to the effects of glare
on account of errors of refraction and heterophoria.

These investigations suggest that the first indication of visual fatigue is
shown by fatigue of accommodation. Although this condition causes discomfort,
yet there is no correlation between mild accommodative asthenopia and
inability to estimate distance on landing an aeroplane. It is only when there
is a marked receding of both near points—about 30 per cent, defective, or spasm
of accommodation, that we notice a tendency to make an error of judgment.
The importance therefore lies in the fact that receding of the near point is the
sentinel symptom of eye fatigue, and calls our attention to the necessity for
further examination.

We now' pass to the question of

Glare and Convergence.

Good convergence is necessary in order to maintain the highest degree of
binocular stereoscopic vision. The association between glare as the exciting
cause of a breakdown or weakness of convergence was, therefore, the next step
in our investigations.

A few preliminary words in explanation of the mechanism of convergence
are desirable.

Starting Point of Convergence. —We do not know exactly what position
the eyes would take during life in the absence of any converging innervation,
though the divergence which follows monocular amblyopia seems to show that
it would be one of considerable divergence. Le Conte has shown that during
sleep, and even in his case during drowsiness, the eyes diverge, as they also
do in drunkenness, under chloroform and at death.

Tonic Convergence .—All muscles possess physiological tone. By this tonic
contraction, the visual axes are brought into a condition of parallelism, so that
on viewing a distant object, and occluding one eye, the vision either remains
undeviated, or the object only moves slightly.

Exophoria in distant vision indicates a deficiency, and esophoria an excess
of tonic convergence.

Accommodation and Convergence.

When a person with a normal pair of emmetropic eyes looks at a near
object, the eyes converge in order that both visual axes may be directed at the
object. At the same time the eye “ accommodates,” in order that the rays of
light may be accurately focussed on the retina.

50 Rippon: Effect of Tropical Climate on Efficiency

These two functions, accommodation and convergence, are in ordinary life
always employed together, so that they have become “ associated/’ It is
difficult, therefore, for a normal pair of eyes to accommodate without con¬
verging, or to converge without accommodating. As a rule, each diopter of
accommodation is associated with about three-quarters of a metre—angle of
associated convergence, so that in a typical emmetrope, the 4. diopters of
accommodation in exercise for vision at a quarter of a metre, are accompanied
by 3 ma. of convergence. The deficit of 1 ma. is made up by a visual reflex
action known as the “ fusion reflex,” which protects us against seeing double.
This fusion function is maintained in activity by the psychical level, and in
the expression of the desire for single binocular vision.

Maddox holds that this “ fusion convergence ” involves greater wasting of
co-ordinating nervous energy than “ accommodative convergence ” and suggests
that it is the cause of the “ muscular asthenopia ” described by Von Graefe,
which Maddox believes to be really a “ central asthenopia.”

Investigations into Glare and Convergence in India.

The optometer was used in measuring the convergence in the cases
previously described. Both eyes were uncovered, and the carrier moved
towards the eyes until the hair or a thin black line appeared doubled. This
was the point we estimated as the near point.

Analysis of Results .—Since my return to England, I have submitted my
figures to Wing-Commander Clements [7] for criticism, and find that he grades

cases in a simple and satisfactory way as follows:—

Condition

( Outside 4 in. ...

Poor

Near point J From 3 to 4 in.

Fair

of convergence 1 From 2 to 3 in.

Good

1 Inside 2 in.

Very good

The optometer we used in testing the power of

convergence in the cases

described only registered accurately up to 2*8 in. so
cases as

that I have classified our

(A) Good.

... 3 in. and under

(B) Fair ...

... 3 to 4 in.

... Outside 4 in.

Taking this standard we find that in Series 1 (cases of glare occurring in
April)—

Three cases had ^ood convergence
Two cases had fair convergence
Eight cases had poor convergence

In Series 2 (taken in May and June when the effects of glare were felt
more severely) every case was graded “poor.” The mean average being 7*5 in.
(equal to 5*6 metre angles) compared with 4*3 in. (equal to 8*1 metre angles) in
the April cases. Showing marked deterioration during the hotter months.

The controls show a mean average of 4*2 in. and 3*75 in. respectively,
after an average of nineteen months exposure to tropical conditions.

In Series 1 there were six good cases, five fair cases and three with poor
convergence. The poor cases all complained of symptoms of glare.

In Series 2 there were three cases of good, six of fair, and three of poor
convergence.

War Section

Experience.

In assessing the deleterious effect of eye fatigue in pilots, allowance must
be made for the experience of the individual and his ability to fly.

A degree of eye fatigue, which, in a beginner, would certainly be associated
with errors of judgment on landing, might not produce any apparent difference
in an able and experienced pilot. Nevertheless, we find that an experienced
pilot whose eyes show signs of “ wear and tear,” although he may still land
well, will admit that he no longer lands “ automatically,” but does so with
conscious care and deliberation, and frequently with apprehension that he may
crash.

At Medical Boards, we often meet with cases of “ anxiety neurosis ” where
the predisposing cause is eye fatigue and constant fear of crashing on landing.
Hence the importance of preventing the onset of a psychoneurosis by careful
observations of the visual apparatus. By stepping in at the right time and
recommending a tired pilot for a rest, we may keep our personnel up to the
high standard of fitness required.

Conclusions.

The most recently acquired faculties are always the first to be lost, and the
44 stereoscopic sense,” belonging to the psychic level, is probably one of the
most recent acquirements of the human race.

These visual reflexes are the “ semi-mechanized results of successive mental
adaptations effected by the mental efforts of successive generations.”

In some individuals there is an inherent power or 44 vital force ” which
enables them to retain their binocular stereoscopic vision under adverse con¬
ditions or stress, others under similar conditions will suffer, and in these cases
we may consider that there is an inborn tendency to break down, in the same
way that the investigations of Sir Frederick Mott [13] have shown that there is
an inborn tendency (associated with definite changes in the endocrine organs and
cortex) in certain individuals to develop dementia prsecox at puberty, or mania
during childbirth.

This conception of “ resistance ” explains why some complain of the glare
and others do not.

We cannot always prophesy whether a candidate with normal vision will Irreak
dozen and develop eye trouble during training , becazcse we cannot estimate his
neuropathic and psychopathic predisposition with sufficient accuracy at present .

What we aim at achieving is by careful and repeated examinations during
the entire period of a flying officer's service , to satisfy ourselves that no visual
deterioration has occurred such as may result in an error of judgment on landing .

(II) Tropical Climate and Mental Efficiency.

There appears to be no doubt that tropical climate impairs mental efficiency,
and is a predisposing cause to psychoneurosis. Woodruffe [11] has shown
that the blonde white race suffers from tropical light, and eventually tends
to die out. Isaac Taylor [12] states that there is no third generation of
unmixed European descent in the tropics, as they become sterile. Sterility
suggests an endocrine basis for our tropical psychoneurosis, just as the war

52 Rippon: Effect of Tropical Climate on Efficiency

neurosis was often associated with disturbed endocrine balance. Our psycho¬
neurotic patients however, almost invariably had some mental conflict, and
considerable relief was obtained by treatment with suggestion, persuasion or
analysis.

Factors which Predominate.

Let us briefly consider the various factors which we notice during residence
in the plains of India:—

(1) Fatigue. —There is no doubt that the fatigue caused by the heat and
glare of the sun, the irritation of the skin from prickly heat and insect bites,
the loss of sleep at night, the lack of nourishing food, the periodical attacks of
gastric disorder, &c., definitely diminishes the control normally exercised by
the higher mental faculties over the lower mechanisms of the nervous system.
Hence, irritability and attacks of anger over trivial incidents, a tendency to
magnify small unpleasantnesses, together with lassitude, lack of ambition,
and ability to concentrate for any length of time, are the symptoms which
are readily noticed towards the end of the hot season.

The intelligent adaptation of one's habits to environment may discount a
great deal of the disabilities caused by climate, but before the method is
learned and acclimatization has occurred, there m&y be sufficient loss of control
to predispose the subject to a psychoneurosis.

(2) Self-criticism , Race-hostility , dc. % as Factors associated with Psycho¬
neurosis. —India is an ideal place for the development of a psychoneurosis or
psychosis in a potential psychopath. The European is living in the midst of
potentially hostile races. The story of the Mutiny is still remembered, and
the riots in the Punjab in 1919 are not forgotten. The recent Afghan War
and the Waziristan Campaign were associated with stories of mutilation of
prisoners and the prevalence of looting at night in frontier stations is dis¬
turbing to sleep. Evidence of this factor as a cause of psychoneurosis is
found in the way Europeans congregate at the clubs in Indian stations.
However small the station is, there is always a club, and in the evening
practically every European in the station goes there.

Social functions, dances and entertaining have an importance in India that
is out of proportion to the pleasure which is ordinarily obtained, and the ex¬
planation suggested is that the herding together of Europeans is a protective
measure induced by the anxiety caused by their small numbers in the midst of
an alien race. This anxiety shows itself in the exaggerated desire to maintain
“ prestige.” The European feels that he is always under critical observation,
and seldom relaxes his watch over his behaviour lest he should lower himself
in the eyes of his servants. Inexperienced officers frequently pay absurdly
high wages and allow themselves to be cheated rather than admit that they
cannot afford to pay the prices asked, through fear of losing “ caste.” Thus, to
the constant strain of self-criticism and observation is added that of financial
difficulty, which in the case of married officers is certainly the most serious
problem of life in India.

(3) Financial Worry. —Poverty is generally regarded as a crime. We have
often noticed people whom we know to be “hard-up” giving absurdly high
tips and trying to conceal the crime of poverty. Whilst I know of instances in
which financial worry is unavoidable—such as stoppages of pay through
clerical errors on the part of the pay agent, debts contracted by an extravagant
wife, &c.—yet my observations have impressed me that entertaining and dinner
parties, dances, and standing drinks at the club, are an important source of

War Section

financial worry. The lot of the married officer commanding a squadron, and
others from whom entertaining is expected, is particularly hard, for he feels
that public opinion obliges him to entertain so as to keep up the position of
his rank.

(4) Psychoneurosis in Flying Personnel .—Added to the factors mentioned, the
flying officer has the strain of adaptation to a new environment, that is, the
air. The view taken by R.A.F. medical authorities is that the chief cause of
psychoneurosis in flying officers is a failure to suppress the disturbing emotions
produced by the instinct of self-preservation. This failure is due to crashes,
forced landings, &c., or to weakness of the higher controlling forces—either
innate or acquired, the latter being in many cases associated with toxaemic
states.

(5) Visual Disorder as a Cause of Psychoneurosis .—We have shown that
when the pilot has acquired the art of flying, various manoeuvres are performed
without conscious thought or “ automatically.” With the onset of eye-fatigue
and lack of ability to estimate distance on landing, the pilot has to perform
this act with conscious care, often flattening out too soon so as to avoid
crashing, and this is accompanied by the emotion of anxiety. As one pilot of
great skill and resolution (whose eyes were fatigued by glare) said to me in
India, “ Whenever I start to land, I wonder whether I am going to crash.”
His landings, owing to his skill, were still safe, he knew the performance of his
machine, and there was no obvious bad landing such as one would find in a
novice with the same degree of defective vision, and his amour-propre would
not allow him to ask for a rest. Another pilot, with marked hypermetropia,
who, as a scout pilot, won the D.S.O., told me “ My landings are erratic, but
it is due to nervousness.” He confused cause and effect.

Physiogenic or Psychogenic Origin.

The question is often asked why certain individuals develop nervous
symptoms) whilst others do not.

The physiogenic theory, according to Sir Frederick Mott [14], presupposes
an inherent germinal narrow physiological margin of normal functional
capacity of the brain; and stresses which may be physiological (e.g., adolescence
or pregnancy), pathological (thyroid insufficiency; microbic toxins, &c.), or
psychological (emotional shocks, conflicts, &c.), reveal, excite or accelerate a
genetic inadequacy, causing a disintegration of the psychic unity.

The psychogenic school believes with Jung [15] that there is a certain
predisposition from which arises a non-adaptable psychological function, which
may develop into manifest mental disorder. In proof of this conception is the
statement that we have no proof of the primary nature of the organic disorder,
but overwhelming proofs exist of a primary psychological fault in function,
the history of which can be traced back to the patient's childhood.

Tropical Climate and Psychoneurosis.

In conclusion, I think we may agree that tropical climate plays a primary
part by undermining or lowering the bodily resistance, secondly, mental
factors, such as conflicts come in during this debilitated state and determine
the nature of the psychoneurotic symptoms. Imperfection of organic functions
tends to produce an undue prominence in consciousness of the bodily self and,
therefore, an introspective and brooding habit of mind. It is during this stage
that problems seem so hard to face, decisions cannot be made and sleepless

54 Rippon: Effect of Tropical Climate on Efficiency

nights or nightmares develop. In the worst cases, the family history and
early life clearly indicate a psychopathic tendency—and it is suggested that
in selecting individuals for service in the tropics, we should take this into
consideration.

REFERENCES.

[1] Bonders, “Anomalies of Accommodation.” [2] Maynard, “Manual of Ophthalmic
Practice.” [3] Elliott, “Tropical Ophthalmology.” [4] Swanzy, “Diseases of the Eye.”
[5] Howell, “Text-book of Physiology.” [6] Lawrence, “Visual Optics.” [7] Clements,
Visual Sub committee Report on Visual Requirements of Pilots. [8] Air Ministry Memo.,
“ On Visual Requirements of Pilots.” [9] Maddox, “ On Prisms.” [10] Bishop Harman, ** Aids
to Ophthalmology.” [11] Woodruffe, “Effects of Tropical Light on White Men.” [12J Isaac
Taylor, “ Origin of the Aryans.” [13] Sir F. Mott, “ The Genetic Origin of Dementia Praecox.”
[14] Sir F. Mott, “The Reproductive Organs in Relation to Mental Disease, Psychology and
Medicine,” Brit. Med. Joum., March 10, 1923. [15] Juno, “Analytical Psychology.’* [161 Hart,
“Psychasthenia.” [17] “Report on the Health of the R.A.F., 1921" (Functional Nervous*
Disorder) ” (Air Ministry). [18] McDougall, “ Social Psychology,” “ The Group Mind.”

INDEX

Proceedings of the Royal Society of Medicine, Yol. XYJ, 1U22-23

INDEX

Note. —The Occasional Lectures in the Society’s Proceedings are indicated by the abbrevia¬
tion Occ. Led. They are placed first in the bound volumes under the heading
“ General Reports.” They are followed by the Proceedings of the Sections, which
are arranged alphabetically, each Section being separately paged. The Proceedings
of the Sub-section of Proctology are included in the Section of Surgery and indicated
by the abbreviation Prod, preceding the numerals. The page references indicated
by the numerals under the heading Med. and Ophth. refer to the combined discussion
held by the Sections of Medicine and Ophthalmology, the report of which appears in
the bound volumes immediately after the reports either of the Section of Medicine or
the Section of Ophthalmology. The page-references indicated by the numerals
under the heading Obst. and Therap. refer to the oombined discussion held by the
Sections of Obstetrics and Gynaecology and Therapeutics and Pharmaoology, the
report of which appears in the bound volumes immediately after the reports either
of the Section of Obstetrics and Gynaecology or the Section of Therapeutics and
Pharmacology.

N.B.— The Section of History of Medicine being again included in the whole volume of the
Proceedings , the entries relating to that Section are, as before, contained in this Index.

Abdomen, acute suppurative conditions of, oper¬
ations for, value of experience in, Surq.
5

Abdominal glands, calcified, relation of, to
urinary surgery (Sir J. Thomson-Walker),
Urol. 1-17

see also Lymphatic glands, abdominal
muscles, rhythmical stimulation by interrupted
currents, Bain. 14, 15

pain in case of acquired chronic haemolytic
jaundice, Med. 74

Abdomino-an&l operation for cancer of rectum,
operation June 11120, present condition of
patient (H. Brown), Prod. 89
Abductor paralysis, bilateral, causing stenosis of
larynx, operative methods in treatment,
with special reference to new method by
which airway may be permanently
enlarged and patient decannulated (Irwin
Moore), Laryng. 32-38

cases of, unilateral and bilateral, proportion of,
Laryng. 32

double, case (A. A. Smalley), Laryng . 94

ventriculo-chordectomy for, case (W.
Howarth), Tjaryng. 47

Abortion, instruments used to procure, pushed
through wall of uterus, Obst. 43
Abscesses, ischio rectal, new method of treating
(J. P. Lockhart-Mummery), Prod. G5
Acarus, from case of mange in human being
infected by dog (A. Whitfield), Derm. 75
human, comparison with Sarcoptes canis t Derm.
76

male and female, extracted from one burrow
(A. M. H. Gray), Derm. 87

Accidents, mortality from, among coal-miners
(ages 25-64), period 1890-1912, Epid. 88

Accommodation, amplitude of, definition, War
46

convergence and, War 49
estimation by optometer, War 47
in cases with complaint of glare, investigation
of, War 46

insufficient range of, and asthenopia, association
between, results of investigations into,
War 47, 48

Accommodative asthenopia in Egypt, War 49

Acetabulum, operation for making upper lip to,
in treatment of congenital dislocation of
hips, Orth. 17-19

Acetonuria and diaceturia, persistent, in case
of enlarged liver (C. Worster-Drought),
Child. 56

Achlorhydria, association with dental sepsis,
Odont. 30

Acholuric jaundice, cases of (V. Coates), Clin.
28 ; (I). Paterson), Child. 41 ; (R,

Hutchison), Child. 41

Acidosis theory of rickets, definition of term,
Child. 2, 3

Ackland, W. R.—Discussion on dental sepsis,
Odont. 28

some considerations for preventive dentistry,
Odorit. 15

Acne agminata. cases of (Capt. Bruce), Derm. 16;
(E. G. Graham-Little). Derm. 15
scrofulosorum, case of (A. M. H. Gray), Derm.
101

varioliformis, case (W. K. Sibley), Derm. 108

Aconite, sedative action on horses, Therap. 44

Index

Acromeg&ly in girl aged 16 t with congenital heart

disease (aortic stenosis), case (E. Stolkind), (
Clin. 22

Acromion process, left, epiphysis of, injury to
(P. B. Roth),

Acustieus tumour (right), case of; operation by
Sir V. Horsley in 1912; removal of tumour;
recovery (P. J. Cleminson and F. M. R.
Walshe), Otol. 31, 32
tumours (F. M. R. Walshe), Otol. 32

symptoms due to compression of anterior part
of lateral lobe of cerebellum, Otol. 35
symptoms due to involvement of fifth, facial
and sixth nerves, Otol. 33, 34
symptoms of raised intracranial tension, Otol.

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