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ordinary food and to get out of doors. On Oct. 6th she hadan attack rather more severe than usual. The abdomenbecame a good deal more distended and, as on admission, thedistension was chiefly on the left side, where a coil of gut inactive peristalsis was observed The patient was put onnutrient enemata of peptonised milk and the rectum waswashed out every morning, fæcal material and some shreddymucus being obtained. Nothing was felt by the rectum. Onthe 9th the vomit was faecal in smell and dark brown incolour. Her condition was getting steadily worse and she wasseen in consultation by one of the honorary surgeons at 1 P M.and it was decided that she was suffering from subacute ob-struction probably due to a polypus in the sigmoid flexureor perhaps to the band which had been noted on Sept. 23rd.If her symptoms did not improve it was arranged to performa laparotomy, but it was decided to wait a little longer asshe had had several attacks before and to operate during aquiescent period if possible. At 5 P.M. she returned a largequantity of peptonised milk representing three or fournutrient enemata from the rectum and became very collapsed.Dr. Read was summoned and it was decided to operate atonce but the collapse increased and she died at 6.30.Necropsy.-The post-mortem examination was held on

Oct. llth. On opening the abdomen the first thing to attractattention was a coil of greatly distended small intestinelying in the left flank, to which were adherent omentum andsome collapsed small intestine. On separating the adhesionssome pus was found which was confined to the left side by aband of omentum which was adherent to the pubes and thebrim of the pelvis. A small rupture was found in the smallintestine through which an intussusception could be seen.After removing the intestines and opening them a largepolypus was found near the duodeno-jejunal junction ; abouttwo feet down the jejunum was the intussusception whichwas about six inches in length, at the apex of which was alarge polypus. There was a smaller polypus about half wayup the entering layer of the intussusception. There was alarge collection of polypi in the cascum and lower part of theascending colon and there were three smaller ones in thetransverse and upper part of the descending colon. Nopolypi were found in the sigmoid flexure or rectum.Remarks by Dr. HARVEY.-The above case may be of

interest on account of the length of time the illness lasted,the indefinite and in fact somewhat misleading nature of thesymptoms, and the unusual condition found post mortem.I am greatly indebted to Dr. Read for permission to publishthe notes of this case.

Medical Societies.CHELSEA CLINICAL SOCIETY.

Discussion on " Internal Secretion" in Disease and inTreatment.

THE annual clinical debate of this society was held at theChelsea Dispensary, Manor-street, King’s-road, London, onMarch 8th, Dr. T. VINCENT DICKINSON, the President, beingin the chair.

Sir LAUDER BRUNTON, in opening the discussion, saidthat he thought it better to take a general view of thesubject. He would mention that one of the first experimentson the subject of the excretion of ferments by bacteria wasone by Dr. A. Macfadyen and himself, in which they foundthat not only did bacilli excrete peptonising fermentsbut that those bacilli showed the power of adaptingthe secretion of ferment to the medium upon which theygrew in almost exactly the same way as the pancreas of a dogwill adapt itself to the food upon which the animal hadfed, secreting a glycogenic ferment when the animal wasfed upon starch and secreting a ferment which would splitup fats when the animal was fed upon fats. It would seemfrom recent researches that the ferments which were

excreted into the intestine after their absorption met withcertain anti-bodies and again became recombined to formzymogens. They did not know what these anti-bodies werebut it would sometimes seem that those anti bodies mightreally be active ferments and that in the case of the

pancreas, while it was pouring out into the duodenum asecretion which would convert starch into sugar, it was

pouring out through the lymphatics into the blood anotherferment which would destroy that very sugar and allow it

to undergo combustion in the body. They had there, then,in the pancreas apparently a double secretion, one of whichthey might term the external secretion, as distinguished froman internal secretion where the fluid from the gland wasnot poured out upon a free surface but into the blood.

Apparently those two secretions were dependent upondifferent parts of the pancreas. In the case of diabetes

they seemed to have a disease depending upon failure of theinternal secretion but his own experiments to supply a glyco-lytic ferment in cases of diabetes although not entire failureswere comparative failures. The most striking of all theinternal secretions, however, was that of the thyroidgland. He had occasion once to see nearly all the

symptoms of exophthalmic goitre with the exceptionof the enlargement of the thyroid and the protrusionof the eyeball produced by an overdose and over-

long continuance of thyroid administration for myxcedema.Most of the symptoms of exophthalmic goitre were due toactual poisoning by the internal secretion. In cases of

exophthalmic goitre he used to depend very much uponbromides and upon lime in one form or another, and some-times he seemed to see good results from those ; but theresults were not so well marked or pronounced as one

would have liked. He had since tried extract of supra-renal capsule and that he thought produced a certainamount of benefit. He had tried thymus but hisresults had not been very good with that either.Extract of suprarenal capsule had an almost entirelydifferent action upon the blood-vessels and upon theheart from the extract of thyroid. The latter was one ofthe most marked vaso-dilators he knew and it had beenexceedingly useful where they had the fingers becoming deadin winter time and where the patients suffered much fromchilblains. By putting them upon small doses of thyroidextract they got the vessels of the fingers dilated andchilblains thus prevented. Extract of suprarenal capsulecontracted the vessels to an enormous extent and also stimu-lated the heart ; so between the two they got the bloodpressure very much raised indeed ; in fact they knew no drugwhich would raise the blood pressure to such an extent assuprarenal capsule, except nicotine, and one did not know atpresent whether the nicotine which people took in smokingmight not be an adjunct to the action of the suprarenalcapsules in keeping up the blood pressure and so keeping upthe general tension and power of the individuals. But anotherquestion arose in connexion with the agitation in relation toyouthful smoking. If suprarenal extract counteracted theeffects of thyroid might not nicotine to a certain extent? One of the uses of thyroid was to increase growth. Its effectswere more marked in cretinoid dwarfs than in others buthe had seen a marked growth following in a child who wasnot cretinoid by the administration of thyroid extract.

Probably it would be said that that was post and not propterhoc. But he thought it was propter hoc. And the ideaoccurred to him that it was possible that juvenile smokingmight have the effect of counteracting the effect ofsome of the glands which would tend to cause growthand thus to stunt the growth of the child. But itwas the pituitary body which seemed to be the glandwhich regulated the growth of the child and disease ofthat was often followed by acromegaly and also bythe enormous growth of the patient, so that he becamea giant. Ovarian extract had been used, especially incases of women at the menopause, and he thought he hadseen sometimes a certain amount of benefit by giving ovarianextract in cases where women were complaining very muchof the flushes of heat which were so common at the meno-pause ; but even with that he had not obtained any verymarked results. The kidney was another organ whichseemed to have an internal secretion as well as an externalone. With increased knowledge of the enzymes formed bythe glands, of their reabsorption, the changes they under-went, and of how to get both enzymes and zymogens ifpossible, and if they could know how to split up thosezymogens in the blood afterwards, then their powers oftreating disease would be enormously increased.

Sir VICTOR HORSLEY said that after all the work whichhad been done on the thyroid gland, and after all the well-known clinical results obtained by the use of thyroid extractin a disease like myxoedema, they had rather got the ideaclinically that when they considered an internal secretion andits alterations by disease they thought only of its banish-ment. With regard to the thyroid gland at the presenttime the idea of the internal secretion of that gland.

799

being altered by disease was simply that it came to an I cend. There was not merely that negative side of internal r

secretion, the po-itive side was as important clinically. The internal secreting glands when diseased were no longer r

able to furnish the useful ingoing ferment and in the B

process of becoming diseased poured into the circulation c

not merely a healthy ferment but aberrant and poisonous E

substances. In certain well-known conditions like simple i

goitre there was ample clinical evidence of such poisoning going on. The thyroid adjusted itself to the requirements of the organism chemically and prevention of that was seen in s

disease, especially in the formation of new growths. Ex:-

ophthalmic goitre was a condition in which the thyroid gland was responsible for certain nerve symptoms and the clinical itreatment of exophthalmic goitre at present was apparentlybased upon an attempt to treat the external secretion of the 1

gland. There were few cases of exophthalmic goitre which 1

could not be cured by systematic treatment with the faradiccurrent carried out persistently. Many cases had been

brought to him for operation in which operation had beenavoided by the energetic use of the faradic current, not the constant current, as was sometimes used by mistake. Sup-posing the electrical treatment not to have produced a bene- ficial effect it was curious that in exophthalmic goitre the division of the isthmus by a surgical operation might stopthe disease. There was one other condition in relation tothe operative treatment of exophthalmic goitre which broughtthem to a very interesting conclusion with regard to internalsecretion. When it was first proposed to operate in exoph-thalmic goitre people immediately took it up without con-

sidering the cases or without knowing exactly why they weredoing the operation and the result was that a large numberof deaths followed the operation. In such cases if most of thethyroid gland was removed the patient was practically broughtto the same condition as a carnivorous animal from which thethyroid gland had been suddenly removed and in which thetemperature rapidly rose if it were young, with tremors,dyspnoea, and death. Such was exactly the same clinicalpicture in cases of rapid death after removal of one laterallobe of the thyroid gland in exophthalmic goitre. That wasa proof in itself of two different processes in the gland, theabsence of the internal secretions and also the existenceof the toxic condition. In cases of adenoma of the thyroidgland when the condition was advanced there would befound symptoms of toxicity. The patients were beingpoisoned precisely in the same way as in exophthalmiccases, only in a much less degree. At the presenttime thyroid extract was frequently given in goitre.Thyroid extract given internal,y could not have anysupplementation effect in the case where the new tissueswere poisoning the patient already. On the contrary thepatients often said it made them much worse. In paren-chymatous goitre thyroid extract produced a beneficialeffect for some time-it did not cure it or avert an operationultimately but it made the patient better and it was easyto understand why it should. By giving the thyroid extractthey were doing a judicious thing-they were supplement-ing the failure to the patient of his thyroid gland and pro-viding against his athyroidism. And so markedly was that thecase that where patients had not been treated in that way itwas advantageous to treat them so for a certain time beforeoperating, for by that means the athyroidal condition wasreduced. They were familiar now with the fact that in

malignant disease of the thyroid gland, however localised, itwas absolutely essential to remove the whole gland. Inthose cases, although the gland was completely removed, thepatients required exceedingly little thyroid extract to keepthem in health. With an ordinary myxeedema patient thecustom was to give thyroid extract daily but a carcinomacase did not require it. The thyroid gland which was such anextremely important organ in early life for the growth anddevelopment of the body became of very little importanceevery year after the age of 40 was passed, and most carci-nomata of the thyroid gland began after the forty-fifth year.In other words, it was another proof of the quantitativerelationship between that internal secretion and the needsof the body. Sir Victor Horsley concluded by suggestingthat clinically they ought to look more than they did for thepositive conditions accompanying aberrant internal secretion,for the poisonings which accompanied these secretions, quiteas much as they looked for the loss of normal useful internalsecretion.

Dr. H. D. ROLLESTON said that the theoretical considerationwhich naturally arose was the possibility that some of the

diseases which were assumed to be due to disturbance of thenormal internal secretion of one ductless .gland, such as

exophthalmic goitre, acromegaly, and possibly others, weremore complex in their nature. In acromegaly glycosuriawas not uncommon and had been shown to depend onchanges in the pancreas ; were those pancreatic changessecondary, like the splanchnomegaly sometimes seen

in that disease? Or were they two concomitant changes TAcromegaly might be combined with exophthalmic goitreand there was some superficial resemblance between

acromegaly and myxœdema. It might be argued that

acromegaly was the result of a disturbance of the chemico-physiological equilibrium maintained in health between theinternal secretions of those glands. An anatomical factwhich suggested that there was some inter-relation betweenthe diseases due to abnormal internal secretions was that thethymus gland, which underwent complete atrophy beforeadult life, was almost always persistent or rejuvenated in ex-ophthalmic goitre and sometimes in myxoedema and inacromegaly. The want of success in the treatment of exoph-thalmic goitre and acromegaly might possibly depend on thefact that two or more glands instead of one only were ineach case in an abnormal condition. In the last partof his remarks Dr. Rolleston referred to the therapeuticuses of suprarenal extract. Schafer -and Oliver had shownthat the active principle was not destroyed by gastric juicein vitro and there was no doubt that when given by themouth to patients with Addison’s disease it raised the bloodpressure. It was remarkable that when taken by healthypersons it did not raise the blood pressure. Preparations ofthe active principle were now available for hypodermicinjection and the method was probably more effectual thanadministration by the mouth. The effect of treatment ofAddison’s disease by suprarenal extract or its active principle-epinephrin-was disappointing as compared with the effectsof thyroid extract in myxcedema. Improvement often occurreitemporarily, but it was only in rare instances that the goodeffect was maintained and that anything like a cure was

effected. In Adams’s critical analysis of 105 cases ofAddison’s disease treated by suprarenal extract, the treat-ment had no effect in 49 cases, 33 cases improved coin-cidently with treatment, in 16 cases permanent benefit re-sulted, and in seven cases alarming or fatal results were

produced by the treatment. Although suprarenal extractwas not a marked success in Addison’s disease it had beensuccessfully employed as a local application to constrict theperipheral vessels in operations on mucous surfaces, such asthe nose, eyes, &c., in capillary oozing, in hæmophilia, andin epistaxis. Crile had advocated its use in cases of puresurgical shock as a most satisfactory method of raising theblood pressure ; he recommended that it should be injectedintravenously in large quantities of salt solution, continuouslyand slowly.

Dr. A. E. WRIGHT said the secretions that he wouldspeak about were those which were not elaborated by anygland. The substances he proposed to discuss were thosewhich they all required daily. They were substances ofwhich they did not know where they were created in thebody, but they were present in considerable quantities inthe blood. The most marked type of internal secretion wasdiphtheria antitoxin. All the protective substances involvedin the cure of disease were to be regarded from the pointof view of internal secretions. The blood of a man affectedwith acne was defective in a certain internal secretion.In a patient suffering from acne who was defective in hisprotective substances against that condition in the bloodthey did not know where to get those substances whichwere required. If they took a person who had recoveredfrom disease they would find that he bad got the power ofelaborating the internal secretions required and though theycould not supplement them they could if they knew thelaws by which they were produced help the production ofthose substances in patients. He (Dr. Wright) might be con-sidered venturesome if he said that there was no case of acnewhich could not be cured in a practically short time, butin his own experience there had not been one case which hadnot been curable, though his experience was only some 36cases. There had not been one of them in which he couldnot produce enough internal secretion to kill off the staphy-lococcus. Patients with tuberculosis recovered if they pro-duced enough of the internal secretion to render their bodiesuninhabitable by the tubercle bacillus, and a serum had beenused for the purpose of supplying this. The patient was putinto the open air in the hope that he would elaborate them.

800

Broadly speaking, in a disease of chronic character inclined 1to reinvade people, which was not immediately dangerous tto life, there was an interval during which the secreting r

tissues in the body could be induced to secrete the sub- tstances required. Evidence could be got that they had beenobtained, and in almost all cases, clinically, benefit would (

result. The effect of one inoculation in any disease was notsufficient to increase the amount of protective substances iin the blood so as to change the whole nature of anybody. c

Ordinary inoculation was best carried out by a series of a

repeated doses, and they had to know the law which c

governed those repeated doses to secure success. The c

object of all inoculations was to produce by a series Iof repeated doses an internal secretion by accumulativeeffects. When they dealt with internal secretions it shouldnot be simply a matter of thyroid or acromegaly, but itshould come home as a daily thing in their lives that chronicor local infection was a symptom of defective internalsecretions, and that those secretions could be elaboratedin the body when there were youth, strength, and health bythe application of a stimulant given in the proper quantitiesand at proper intervals and given always in the light ofcareful and systematic examination of the blood.The discussion was then adjourned. ]

t

MEDICAL SOCIETY OF LONDON.

Disoussion on Acute Intestinal Obstruction.

A MEETING of this society was held on March 14th, Dr.F. DE HAVILLAND HALL, the President, being in the chair.

Dr. W. HALE WHITE opened a discussion on AcuteIntestinal Obstruction by communicating a paper on theearly diagnosis of the condition which is published at p. 791of ,the present issue of THE LANCET.Mr. A. E. BARKER confined his remarks to an outline of

the principles of surgical treatment in intestinal obstructionand to the most important details. He emphasised thefact that the condition under discussion was made up ofthree preponderating factors : (1) mechanical or ana-

tomical ; (2) physical ; and (3) vital. It was pointed outthat the mechanical factors per se were not dangerous ifpromptly relieved, as could be learned by the results of

operations for strangulated hernia at an early stage. The

physical factors induced by strangulation were certain tocome on sooner or later-i.e., congestion of the retainedbowel, thrombosis, and effusion, and they became veryserious if neglected. But in the local and general vital

changes due to the action of the toxins stored up under

pressure in the bowel above the point of arrest lay thegreatest dangers to the patient, whether operated on or not.In an advanced case of obstruction therefore the quickevacuation of this stored-up putrid material must be pro-vided for either by artificial anus or, as preferred by Mr.Barker, by resection of several feet of bowel above theconstriction and anastomosis of the remaining parts. The

reasoning in support of this course was only lightly touchedon, having been already published in THE LANCET of

May 30th (p. 1495) and June 6th (p. 1576), 1903. Illustrativecases were quoted, however, and some specimens were shown.A sketch of the chief details to be observed in a case ofacute intestinal obstruction was given and some remarkswere made upon after treatment and complications. Thestomach should be emptied, by stomach-tube if necessary,and the mouth washed out with antiseptics, warm brandy-and-water administered by the mouth, and a saline solutioninjected per rectum. Chemical germicides were, in Mr.Barker’s experience, best avoided but thorough asepsisshould be employed Local analgesia, excepting perhapstowards the end of an operation, was to be preferred to

generalised anæsthesia.The PRESIDENT aluded to a case resembling renal colic

which was ah ’ut to be operated on for intestinal obstructionand in which he prescribed warmth to the abdomen andrest and the patient duly recovered. The responsibility of thephysician in such ca’<es was very great. Some observers hadreferred to leucocytosis as being a characteristic of intestinalobstruction as well as of appendicitis. Urgency of symptomswas an indication of the amount of constriction rather thanits position aq taught bv older authors.

Mr. C CARTER BRAINE was very interested in Mr.Barker’s vit:’ws on the use of local analgesia. He had often

iad an anxious time in the administration of general an&aelig;s-shesia. It was a very good plan to wash out the stomach’epeatedly, since there was a constant tendency to regurgita-;ion of stercoraceous material.Dr. J. VINCENT BELL (Rochester) referred to cases of

>bstruction by a volvulus and by bands of adhesion.Mr. H. J. WARING referred to the diagnosis of true acute

ntestinal obstruction from hysteria. The resemblance was)ften very great, the character of the pulse being a valuabledid. He mentioned a case of hysteria which had been)perated on by four eminent surgeons at different times forobstruction of the bowels. It was of importance to examine)er rectum before diagnosing the obstruction or its cause.

Dr. HALE WHITE and Mr. BARKER replied.

PATHOLOGICAL SOCIETY OF LONDON.

Recent Ex 7) erimental Work on Bacillary Dysentary.-DeepChromatin Staining in Malaria.-An Unusual AnatomicalLesion.A MEETING of this society was held on March 15th at the

oyal Army Medical College, Victoria embankment, Lieu-enant-Colonel R. H. FIRTH, R.A.M.C., being in the chair.Lieutenant-Colonel FIRTH communicated notes on some

Recent Experimental Work concerning Bacillary Dysentery,a which he explained that while there could be no doubt as

the existence of bacilli in the intestinal dejecta fromases of acute dysentery which were capable of differentiationrom the common colon and enteric micro-organisms all theacilli which had been described as being the specific causef bacillary dysentery were probably not so. In the course ofdetailed examination of a considerable number of these

ysentery bacilli, derived from a variety of sources, it wasossible to divide them into those which were pathogenicnd those which were not. Pathogenicity had beenetermined in the rabbit and although both varietiesresented morphological resemblances in common, theistinctive cultural features of the non-pathogenic groupeemed to be an ability to split maltose, galactose,nd mannite with the formation of acid but without pro-uction of gas, also to produce indol. These character-sties were wanting in the pathogenic varieties. The non-

athogenic forms were apparently the " pseudo-dysenteryacilli" " of some authors but whether they representedegraded or transitional forms of the pathogenic type hei,as unable to say. As representative of the true bacilli ofysentery he mentioned the organisms associated with theames of Shiga, Vaillard, and Kruse. After demonstratinghe cultural reactions of. the two types he pointed out thatrom the point of view of their agglutination reactions thewo groups presented marked differences ; whereas the serumerived from animals immunised with one or other of the’athogenic varieties was capable of reacting upon the othernembers of the same group in high dilutions, it had littler no effect upon those of the non-pathogenic group ; more-ver, there was no concordant interaction between membersf this latter group and sera resulting from immunisationyith similar non-pathogenic strains. The same experimentshad shown that in the rabbit, although a serum had developednarked agglutinating functions, it had no antitoxic action.Vhile in rabbits no ill effects followed when the dysenteryorganisms or their toxins were administered either by thenouth or by direct injection into the intestinal tract, as ex-&THORN;osed by a preliminary laparotomy, lesions characteristic ofhose found in human dysentery could be produced by sub-:utaneous inoculation. Examples of these were exhibitedhowing ulcerated and sloughing areas in the cseoum andarge intestine ; also sections of some of the affected parts invhich the bacillus seemed to be affecting primarily the sub-nucous layer of the bowel. The lesions could be caused notmly by injections of living bacilli but also by cultures killed byheating to 60&deg; C. for half an hour; these same effects followednoculations with a sterile filtrate derived from a four-day-old&THORN;roth culture and also with the filtrate obtained from a sterile.utolysed maceration in water of bacilli which had been:illed by chloroform. The existence of toxic broth filtrateshad been denied by some, but provided care were taken toee that the broth in which the dysentery bacilli were grownvas definitely alkaline no difficulty was experienced in obtain-ng a highly toxic filtrate. The dysentery bacilli and the,oxic substances elaborated by, or contained in, their bodiesappeared to have a selective affinity for the c&aelig;cum and large