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932 might be relegated to a secondary position in the causation of gout. It was to be regretted that this line of research had not been extended and it was unfortunate that pure adenin was almost impossible to obtain. Apart from xanthin the amount of alloxur bases appearing in the urine was so exceedingly small that their separate estimation was a matter of great difficulty. Dr. Bain suggested the possi- bility that the retention of adenin within the system might determine the deposition of biurate in the tissues. Dr. A. E. SANSOM confessed that he was still in a maze of doubt as to the pathology of gout, though experiments seemed to be elucidating some of the problems. There was no doubt that the deposit of urates was the cause of a gouty attack ; but why should it, he asked, be afterwards got rid of in some cases but not in others ? 7 The absence of pain, too, in some cases was inexplicable. It seemed to him doubtful whether those violent and destructive paroxysms of acute gout sometimes observed could be explained wholly and solely by sodium biurate. Surely there must be some- thing that was associated with it which prevented metabolism. The subject of treatment also was beset with difficulty. If sodium salts promoted and potash salts delayed deposition why was it that they got such good results from the two together ? Piperazin in his experience did seem to do good in some cases. Laboratory experiments were very useful, but they were still a long way off the truth. The PRESIDENT congratulated Dr. Luff on his welcome and interesting researuhes. He had never thought very much of piperazin or lysidin in the treatment of gom and he had mostly come back to the potash salts or a combination of potash and soda. Dr. Bain’s case was an interesting one and he remembered to have met with a case resembling this in the extreme gouty development without anything to account for it, for the patient was both a teetotaler and a vegetarian. Dr. A. P. LUFF, in reply, thought that the disappearance of the deposit in some cases and not in others depended upon the alkalinity of the blood. If this was high then the blood could not remove the deposits. The presence or absence of pain in different cases depended, he believed, upon the rapidity of deposition. It was the suddenness of the deposition which caused the pain. Referring to the necrosis of certain tissues he doubted whether such a process occurred in cases of true gout. He had never seen necrosis of cartilages in true gout, and he thought it possible that the alleged cases were rheumatoid arthritis on which acute goat had supervened. Dr. Bain’s case bad been very care- fully investigated. He would like to know what were the relative lengths of time for the administration of the different substances. He thought that in so many experi- ments in one patient the gouty state must have been in different phases at different times. The fact that gua1acllm eliminated uric acid was quite, in keeping with his ex- perience and that of Sir Alfred Garrod.’ Given in the form of resin it was certainly a prophylactic. Dr. BAIN, in reply, mentioned the doses and duration of the administration of the different drugs. There was an interval of three days between each, but the patient began by being put on a fixed diet for nine days. He thought the question of pain would depend upon the structures that were involved. As to the necrotic changes he quite agreed with Dr. Luff. Dr. Chalmers Watson had found in chronic gout a myelocyte which was not to be found in normal blood, but Dr. Bain had not found tbis in one case which he had examined. He quite agreed with Dr. Sansom that there must be something besides the biurate to produce gout and he had suggested that it might be adenin. The marked effect which this had had upon the blood-pressure and the occurrence of uric acid in the kidneys of Minkowski’s dogs were arguments in favour of this view. CLINICAL SOCIETY OF LONDON. A Case of Dermoid Cyst within the Spinal Canal.-Reduction of the Deformity of Spinal Caries by -Jfan?tal ect4 fication. A MEETING of this society was held on March 23rd, Sir R. DOUGLAS PowELL, Bart., President, being in the chair. Dr. W. HALE WHITE and Mr. A. D. FRIPP communicated a paper on a case of Dermoid Tamoar growing within the Spinal Canal in which an attempt was made to remove the growth. The patient was a man, aged 26 years, who had been suffering from a very chronic form of Hodgkin’s disease. He was first seen by Dr. Hale White and Mr. Fripp with Mr. A. F. Wilson at the end of March, 1899. In the middle of January, 1899, the patient began to comp’ain of loss of power in the legs. By the end of March there was complete paraplegia without muscular wasting. The breathing was almost entirely diaphragmatic, the right hand was much stronger than the left, and all forms of sensation were lost up to the level of the nipples ; there was no hypera39thetic zone ; there was severe pain shooting down both intercosto-humeral nerves and round the chest along the second intercostal nerves, the lower limbs were rigid, the knee-jerks and plantar reflexes were exaggerated, and there was great superficial tenderness over the second, third, and fourth dorsal spine. There was incontinence of urine with cystitis and obstinate constipation and great distension of the abdomen. The pulse was 120 and the temperature generally was about 101° F. There were no signs pointing to caries and aneurysm. The diagnosis was that there was some collection of fluid or a new growth within the spinal canal irritating the second dorsal nerve and compressing the cord below it. There was no evidence that this was syphilitic or that it was malignant. An exploratory laminectomy was performed, the second, third, and fourth dorsal arches being removed. A grey tumour situated upon the outer surface of the dura mater was exposed, which reached out of sight both above and below. Pieces of the growth were snipped away. The patient quickly rallied from the operation and the wound healed by first intention. The tumour proved on microscopical examination to be a dermoid cyst. The patient was seen again by Dr. Hale White and Mr. Fripp eight weeks later. The pulse and the temperature were normal. There was slight and occasional voluntary movement in the legs. The exaggeration of the knee-jerks was less and the rigidity had disappeared. There was almost complete return of all forms of sensation down to the groins, but no improvement in the lower extremities. The radiating pains had disappeared. The chest moved better. The cystitis and incontinence had disappeared and the constipation and abdominal distension were less. There was a large bedsore on the sacrum and another on the buttock. Considerable as had been the improvement it appeared to Dr. Hale White and Mr. Fripp that as much of the tumour had been left behind, and as the pressure symptoms were far from completely relieved, the only chance of benefiting the patient lay in a further attempt at complete removal. A second opera- tion was performed. A large mass of the tumour was found to have grown backwards through the gap in the spinal canal made at the first operation. The first, fifth, and sixth dorsal laminae were removed, but still no limit could be seen to the growth. The patient rallied well but sank again eight hours after the operation.-The PRE- SIDENT remarked that the case was of interest as bearing on the question how far interference was justifiable in cases of this kind.-In reply to the President, Dr. HALE WHITE said that the case was unique as regarded the nature, though not as regarded the position, of the tumour. Cases of dermoid cysts had been recorded in the middle line between the skin and the spines, but not within the spinal canal. Mr. ROBERT JONES (Liverpool) and Mr. A. H. TUBBY com- municated a paper on the Reduction of the Deformity of Spinal Caries, based on 99 cases of angular deformity from Pott’s disease treated by Manual Rectification, including the results of the 25 cases which had been brought before the Clinical Society of London in November, 1897. In this first series of 25 cases the following results had been obtained: five patients had died, four had discontinued treatment, 15 were alive, well, and able to walk, and one was still re- cumbent and sickly. As to the causes of death, one died four days after the operation, but post mortem no abnormality was found beyond some enlarged mesenteric glands; one died from tabes mesenterica 15 months after the operation ; one died from pulmonary tuberculosis 16 months afrer the last stretching, one from intestinal obstruction twelve months after, and one from diphtheria. Billroth, Menzel, Ja,S6, and Mohr estimated the death-rate from Pott’s disease to be 25 per cent., the death-rate of the series observed by Mr. Jones and Mr. Tubby being only 12 per cent. Four of the cases developed abscesses, of which two healed and one patient became paraplegic eight months after the operation, but had since recovered. Five of the 25 patients recovered from paraplegia as the immediate result of the operation, recurrence taking place in one case. In five cases the curvature was practically obliterated and remained so with a spinal support, and the curve was much improved in ten of the cases. In a parallel series of non- recdaed cases three patients had died from tubercle, four
Transcript
Page 1: CLINICAL SOCIETY OF LONDON

932

might be relegated to a secondary position in the causationof gout. It was to be regretted that this line of researchhad not been extended and it was unfortunate that pureadenin was almost impossible to obtain. Apart from xanthinthe amount of alloxur bases appearing in the urine was soexceedingly small that their separate estimation was a

matter of great difficulty. Dr. Bain suggested the possi-bility that the retention of adenin within the system mightdetermine the deposition of biurate in the tissues.

Dr. A. E. SANSOM confessed that he was still in a mazeof doubt as to the pathology of gout, though experimentsseemed to be elucidating some of the problems. There wasno doubt that the deposit of urates was the cause of a goutyattack ; but why should it, he asked, be afterwards got ridof in some cases but not in others ? 7 The absence of pain,too, in some cases was inexplicable. It seemed to himdoubtful whether those violent and destructive paroxysms ofacute gout sometimes observed could be explained whollyand solely by sodium biurate. Surely there must be some-thing that was associated with it which prevented metabolism.The subject of treatment also was beset with difficulty. Ifsodium salts promoted and potash salts delayed depositionwhy was it that they got such good results from the twotogether ? Piperazin in his experience did seem to do goodin some cases. Laboratory experiments were very useful,but they were still a long way off the truth.The PRESIDENT congratulated Dr. Luff on his welcome

and interesting researuhes. He had never thought verymuch of piperazin or lysidin in the treatment of gom and hehad mostly come back to the potash salts or a combinationof potash and soda. Dr. Bain’s case was an interesting oneand he remembered to have met with a case resembling this inthe extreme gouty development without anything to accountfor it, for the patient was both a teetotaler and a vegetarian.

Dr. A. P. LUFF, in reply, thought that the disappearanceof the deposit in some cases and not in others dependedupon the alkalinity of the blood. If this was high then theblood could not remove the deposits. The presence or

absence of pain in different cases depended, he believed, uponthe rapidity of deposition. It was the suddenness of thedeposition which caused the pain. Referring to the necrosisof certain tissues he doubted whether such a processoccurred in cases of true gout. He had never seen necrosisof cartilages in true gout, and he thought it possible thatthe alleged cases were rheumatoid arthritis on which acutegoat had supervened. Dr. Bain’s case bad been very care-fully investigated. He would like to know what were therelative lengths of time for the administration of thedifferent substances. He thought that in so many experi-ments in one patient the gouty state must have beenin different phases at different times. The fact that gua1acllmeliminated uric acid was quite, in keeping with his ex-

perience and that of Sir Alfred Garrod.’ Given in the formof resin it was certainly a prophylactic.

Dr. BAIN, in reply, mentioned the doses and duration ofthe administration of the different drugs. There was aninterval of three days between each, but the patient beganby being put on a fixed diet for nine days. He thought thequestion of pain would depend upon the structures that wereinvolved. As to the necrotic changes he quite agreed withDr. Luff. Dr. Chalmers Watson had found in chronic gouta myelocyte which was not to be found in normal blood, butDr. Bain had not found tbis in one case which he hadexamined. He quite agreed with Dr. Sansom that theremust be something besides the biurate to produce gout andhe had suggested that it might be adenin. The markedeffect which this had had upon the blood-pressure and theoccurrence of uric acid in the kidneys of Minkowski’s dogswere arguments in favour of this view.

CLINICAL SOCIETY OF LONDON.

A Case of Dermoid Cyst within the Spinal Canal.-Reductionof the Deformity of Spinal Caries by -Jfan?tal ect4 fication.A MEETING of this society was held on March 23rd, Sir

R. DOUGLAS PowELL, Bart., President, being in the chair.Dr. W. HALE WHITE and Mr. A. D. FRIPP communicated

a paper on a case of Dermoid Tamoar growing within theSpinal Canal in which an attempt was made to remove thegrowth. The patient was a man, aged 26 years, who had beensuffering from a very chronic form of Hodgkin’s disease.He was first seen by Dr. Hale White and Mr. Fripp withMr. A. F. Wilson at the end of March, 1899. In themiddle of January, 1899, the patient began to comp’ain

of loss of power in the legs. By the end of March therewas complete paraplegia without muscular wasting. Thebreathing was almost entirely diaphragmatic, the righthand was much stronger than the left, and all forms ofsensation were lost up to the level of the nipples ; therewas no hypera39thetic zone ; there was severe pain shootingdown both intercosto-humeral nerves and round the chestalong the second intercostal nerves, the lower limbs wererigid, the knee-jerks and plantar reflexes were exaggerated,and there was great superficial tenderness over the second,third, and fourth dorsal spine. There was incontinence ofurine with cystitis and obstinate constipation and greatdistension of the abdomen. The pulse was 120 and thetemperature generally was about 101° F. There were nosigns pointing to caries and aneurysm. The diagnosis wasthat there was some collection of fluid or a new growthwithin the spinal canal irritating the second dorsal nerveand compressing the cord below it. There was no evidencethat this was syphilitic or that it was malignant. Anexploratory laminectomy was performed, the second, third,and fourth dorsal arches being removed. A grey tumoursituated upon the outer surface of the dura mater was

exposed, which reached out of sight both above and below.Pieces of the growth were snipped away. The patientquickly rallied from the operation and the wound healedby first intention. The tumour proved on microscopicalexamination to be a dermoid cyst. The patient was

seen again by Dr. Hale White and Mr. Fripp eightweeks later. The pulse and the temperature were normal.There was slight and occasional voluntary movementin the legs. The exaggeration of the knee-jerks was

less and the rigidity had disappeared. There was

almost complete return of all forms of sensation downto the groins, but no improvement in the lower extremities.The radiating pains had disappeared. The chest movedbetter. The cystitis and incontinence had disappeared andthe constipation and abdominal distension were less. Therewas a large bedsore on the sacrum and another on thebuttock. Considerable as had been the improvement it

appeared to Dr. Hale White and Mr. Fripp that as

much of the tumour had been left behind, and as the

pressure symptoms were far from completely relieved,the only chance of benefiting the patient lay in a

further attempt at complete removal. A second opera-tion was performed. A large mass of the tumour wasfound to have grown backwards through the gap in the

spinal canal made at the first operation. The first, fifth,and sixth dorsal laminae were removed, but still no limitcould be seen to the growth. The patient rallied wellbut sank again eight hours after the operation.-The PRE-SIDENT remarked that the case was of interest as bearingon the question how far interference was justifiable in casesof this kind.-In reply to the President, Dr. HALE WHITEsaid that the case was unique as regarded the nature, thoughnot as regarded the position, of the tumour. Cases ofdermoid cysts had been recorded in the middle line betweenthe skin and the spines, but not within the spinal canal.Mr. ROBERT JONES (Liverpool) and Mr. A. H. TUBBY com-

municated a paper on the Reduction of the Deformity ofSpinal Caries, based on 99 cases of angular deformity fromPott’s disease treated by Manual Rectification, including theresults of the 25 cases which had been brought before theClinical Society of London in November, 1897. In this firstseries of 25 cases the following results had been obtained:five patients had died, four had discontinued treatment, 15were alive, well, and able to walk, and one was still re-

cumbent and sickly. As to the causes of death, one diedfour days after the operation, but post mortem no abnormalitywas found beyond some enlarged mesenteric glands;one died from tabes mesenterica 15 months after the

operation ; one died from pulmonary tuberculosis 16 monthsafrer the last stretching, one from intestinal obstructiontwelve months after, and one from diphtheria. Billroth,Menzel, Ja,S6, and Mohr estimated the death-rate from Pott’sdisease to be 25 per cent., the death-rate of the seriesobserved by Mr. Jones and Mr. Tubby being only 12 percent. Four of the cases developed abscesses, of whichtwo healed and one patient became paraplegic eightmonths after the operation, but had since recovered. Five ofthe 25 patients recovered from paraplegia as the immediateresult of the operation, recurrence taking place in one case.In five cases the curvature was practically obliterated andremained so with a spinal support, and the curve was muchimproved in ten of the cases. In a parallel series of non-recdaed cases three patients had died from tubercle, four

Page 2: CLINICAL SOCIETY OF LONDON

933

had developed abscesses (twa of them healing), four hadbecome paraplegic with two recoveries, and in seven thedeformity was very marked. Mr. Jones and Mr. Tubby thenbrought forward a series of 74 cases subsequently operatedon. Of these seven patients had died, 29 were walking,28 were recumbent, and 10 had discontinued treatment.As to the causes of death, one patient died from empyemafour weeks after operation ; one died from general tuber-culosis thirteen days after operation, and another two yearsafter ; one died from pulmonary phthisis eighteen monthslater and one from pneumonia two years after; one diedfrom exhaustion ; and one died six months after reductionfor paraplegia, without relief, from diarrhoea. Three

patients were operated upon while abscess was present and13 developed abscesses subsequently, of which nine hadhealed. Seven patients had recovered from paraplegia,or the condition had been relieved and had remainedso. In 16 the curvature had either not improved or hadbecome worse, but not necessarily as the result of the opera-tion. Mr. Jones and Mr. Tubby deprecated the employ-ment of much force, their plan having been to proceed bystages with an interval of a month between each attempt.They laid it down that the after-treatment should not be lessthan three years. Their conclusions were as follows : (1)that danger to life was inot great; (2) that-far from in-ducing paraplegia the operation was actually a curativemeasure; (3) that abscess formation was, if anything, lessfrequent ; (4) that the risk of disseminating tubercle was anegligible quantity ; and (5) that there was no riskof a flail-like spine. The contra-indications were: (1)cervical and high dorsal curves, unless associated withparalysis; (2) ankylosed spines; (3) large and angulardeformities; (4) evidences of tubercle elsewhere ; (5) inchildren under two years of age and in adults over 22 years;and (6) the presence of abscess unless there were paraplegia.They advised the operation only when the spine was yieldingand in comparatively strong children free from abscess andtubercle. They pointed out that the operation was not toobliterate all the prominence, but to give as erect a positionas possible. Lastly, they urged that cases for operationmust be selected with great care, that personal attention tothe patients must be unremitting, and that fresh airwas an all-important factor in the after-treatment. Theyexhibited a selection of the first series of 25 cases

showing the actual results.-The PRESIDENT observedthat whatever they might think of the ultimate resultsof the treatment the facts brought before themmust materially alter many of their present views. Hasked whether albuminuria due to myeloid disease had dis.appeared when the surgical deformity was remedied.-Mr. JJACKSON CLARKE said that.be had followed the revival ojforcible correction of deformity in spinal disease with grealinterest. He believed that he was the first surgeon t<

perform the operation in London. In order to understandthe results obtained in the cases before the society iwas necessary to consider the methods previously employedMr. Tubby had put it on record that up to 1896 he ha<chiefly used corsets of plaster or of felt. Mr. Clarke ha(found the results of such appliances to be very disappointingMr. Jones had chiefly employed Thomas’s cuirass which waalso used in the after-treatment of many of the cases beforthe meeting. This cuirass, which exerted a leverage actioion the spine, had certain defects, though it was, in MiClarke’s opinion, better than any other corset. It did nolend itself to periodical re-adjustment and thus was n

help to gradual correction of deformity ; it did nc

provide for alterations required by the growth of thpatient, and again it did not readily lend itself to thaddition of a head-piece needed in high dorsal an

cervical cases. By the use of an antero-superior suppoiwhich did not possess these disadvantages Mr. Clarke haobtained results which he believed compared very favourablwith those seen in the cases now shown by the authors c

the paper. Thus in some cases of lumbar disease to

deformity had been obliterated ; in other cases it had beeconsiderably diminished. These results had been obtainesometimes after a period of rest in bed or on the couch, bimore often with ambulance treatment throughout. Tt Ieducational aspects of spinal cases had to be considered ana method of treatment that allowed a patient to be taught!home or to go to school was, other things being equato be preferred to one that demanded two or three yeaof fixation upon an apparatus in the dorsal recumbe:

position. The death-rate of 25 per cent. quoted froBillroth as being observed in cases tiered without forcib

extension was far too high. Even that of 12 per cent.observed by Mr. Jones and Mr. Tubby in the cases whichthey had operated on was distinctly high, being above thatobserved by Mr. Clarke in cases treated in London. It was tobe noted that in more than one of the cases in the paper noreal diminution of deformity had been obtained, and asregarded the future of the patients there was no proof thatas soon as the apparatus was left off deformity would notreturn as the patient grew up owing to damage to the epi-physeal discs. The many contra-indications pointed outwhich would have to be observed in deciding to performforcible rectification approximated closely to Mr. Clarke’s ownviews, which were to the effect that this operation was onlycalled for in exceptional cases. The chief indication was aparaplegia that had resisted a patient trial of gentler means.-Mr. RICHARD BARWELL questioned whether the good donewas as great as they were asked to believe, and he doubtedwhether there had been actual straightening in many of thecases of the angular curve. On the whole he did not thinkthat the results were better than would be obtained in threeyears by other methods of treatment. He observed that inthe case of a child, who was said to have had paraplegia, thechild was under two years of age at the time and possiblywas unable to walk; moreover the mother said that the childhad been able to move his legs. He pointed out that bylifting the patient by the arms and watching the angle it waseasy to see whether the ulcer of the bones had healed. Onthe whole he thought the results were somewhat disappoint-ing.-Mr. BERNARD ROTH said that since seeing these caseshe thought there was more in the treatment than he hadimagined, but he would like to see the cases a year after allinstruments had been left off.-Dr. E. PERCY PATON askedhow long the patients had remained in hospital under treat-ment and he pointed out that prolonged recumbency in thehomes of the poor could not be desirable.-Mr. HOWARDMARSH commended the authors of the paper for the vastamount of patience and labour which they had devoted to thesubject. They must, however, all feel that the subject hadnot been thoroughly threshed out though many interestingpoints had been raised, and he thought the question was onethat might advantageously be referred to a committee forinvestigation and report. He was tempted to raise thequestioii whether the conclusions arrived at by Mr.Jones and Mr. Tubby were justified by the facts whichthey had brought forward. He challenged the estimateof 25 per cent. as the probable death-rate from Pott’sdisease. He himself would put it at 5 or 6 per cent. He

pointed out that paraplegia was equally recovered fromunder other methods of treatment, and he concurred in theview that the correction of the deformity was often moreapparent than real.-Mr. BERNARD ROTH seconded thereference to a committee, and some discussion ensued

I as to the scope of the reference and the way inwhich the inquiry could be carried out. Ultimately

j the proposal to nominate a committee was agreed. to, the precise terms of the reference to be submittedl to the council.-Mr. TUBBY, in reply, said that he thought itl would be conceded that they had done their best to fulfil. their pledge of two years ago to follow up those cases. He; pointed out that they did not insist so much upon the values of the operation in remedying the curve. With reference toi albuminuria he said that it disappeared when the abscessceased discbarging and no patient had died from lardaceoust disease. He did not believe that equally good results could be) obtained with instruments. In reply to Mr. BARWELL he saidt that the child stated to have had paraplegia had the lowere limbs rigid with exaggerated reflexes and could not walk. Hee added that the labour, difficulty, and anxiety entailed by the1 endeavour to afford the society such a demonstration oft results as that before them were very great, and he did not1 think that they could in any way manage to approve of a9 committee being sent about the country to inspect theircases, but the committee would, of course, be welcome toe egamine the records.n &mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;

CHELSEA CLINICAL SOCIETY.

The Treatment of Rheumatism.THE adjourned meeting of this society from March 13 h

was held in the Parish Hall, Pavilion-road, Chelsea, onMarch 20th, Mr. FOSTER PALMER being in the chair.The CHAIRMAN said that at the last meeting the Treat-

ment of Rheumatism which they principally heard about, and


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