895

Dr. H. C’. G. SEMON, in the discussion which followed,desired to associate himself with the President in an expres-sion of his very cordial appreciation of Dr. Lazarus-Barlow’sexceedingly lucid and interesting lecture, and referred shortlyto a case which amply illustrated the latter’s warningagainst the use of radium immediately subsequent to surgicalremoval of malignant growths.. A well-known surgeonrecently removed an epithelioma from the pyriform fossaby lateral pharyngotomy in an old man of 74. Much againsthis inclination he was persuaded to insert a tube con-

taining 100 mgm. of radium in the wound, which was partiallyleft open for that purpose for a period of 24 hours.Ten days later, after primary union had taken place, thewhole wound broke down and a slough of the size of half-a-crown formed in the pharynx and led to a fistulous com-munication with the exterior, a result which was entirelyoutside the very considerable experience of the operator, andone which in his opinion could only have been produced bythe devitalising action of the radium emanations on thenormal tissues. Regarding the quantity of radium best

employed as a dose at the present time Dr. Semon quotedfrom the experiences of Professor Bumm and ProfessorD6derlein,l who had had considerable experience in the treat-ment of malignant disease of the cervix and uterus. Theseauthors had entirely given up the use of large doses and theirpractice was to use not more than 50 to 60 mgm. of the saltat any one application. Professor Bumm had stated that300 mgm. doses would produce a rise of temperature as highas 106° F. in a few hours, and that 500 mgm. were positivelydangerous to life. Dr. Semon asked if Dr. Lazarus-Barlow could support this statement from his own experi-ments, and also whether his opinion of lead filters coincidedwith that of Professor Bumm, who had stated that they shouldnever be used because of the dangerous secondary radiationsproduced in them by the -y rays. This author maintainedthat they were the probable cause of the hyaline degenera-tion of normal fibrous tissue, which not infrequently followedthe application of radium after a latent period of six monthsto a year, and which had in consequence of the productionof hard strictures led to the erroneous belief that a malignantrecurrence was in course of development. Dr. Semon askedif the lecturer had ever met with this complication.

Dr. W. A. MALCOLM asked Dr. Lazarus-Barlow how it wasthat X radiation was of such undoubted value in recurrentnodules after breast operations, whereas the contrary wastrue of radium.

Mr. CECIL ROWNTREE quoted a case of periosteal sarcomaof the femur in a woman, where the growth had not beenmuch affected by radium, but where the effect on the patientwas wonderful, for instead of being bedridden she couldwalk up and down the ward and was quite cheerful.

DEVON AND EXETER MEDICO-CHIRUR-GICAL SOCIETY.

Diseases of the (}!,’sopna,q1bs.A MEETING of this society was held at the Royal Devon

and Exeter Hospital on Feb. 20th, Dr. RANSOM PICKARD,the President, being in the chair.

Dr. WiLLlAM HILL (London) gave a lecture on ModernMethods of Diagnosis and Treatment in Diseases of the (Eso-phagus, with especial reference to the Employment of Radiumin Malignant Sbricture. After demonstrating the method ofinspection by oesophagoscopy and cesophago-gastroscopy onpatients under cocaine anaesthesia, 100 lantern slideswere shown illustrating the following points : 1. Themode of formation, anatomical characteristics, radiographicand cesophagoscopic diagnosis and treatment of so-called’’ aesophageal pouches" " (pharyngeal diverticula), with

skiagrams of six cases under the author. 2. The diagnosisand treatment of foreign bodies. 3. Non-malignantstrictures, with special reference to treatment by variousmethods of dilation and by intubation. No unequivocalcase of idiopathic spasm-e.g., cardiospasm-had been metwith in the author’s large experience. 4. Various types ofmalignant stricture. 5. The forms of radium apparatusemployed by the author, their method of introduction,statistics of results, and skiagrams taken before and aftertreatment. The improvement in many instances was not

1 Brit. Med. Jour., Dec. 13th and 27th, 1913.

only marked as regards subjective symptoms, but was

objectively shown by the eesophagoscope and by radio-graphy. All present had an opportunity of observing throughthe oesophagoscope a stricture, formerly fungating, whichhad been held in check for four years by eight applicationsof radium made at intervals.At the termination of the lecture a vote of thanks, pro-

posed by Dr. W. GORDON, and seconded by Mr. R. A.WORTHINGTON, was awarded to Dr. Hill by acclamation.

Treatment of Uterine Myomata by X Rays.A MEETING of this society was held at the Royal Devon

and Exeter Hospital on March 13th, Dr. PICKARD, the

President, being in the chair.Dr. J. DELPRATT HARRIS read a paper on the Treatment

of Uterine Myomata by X Rays. In this it was stated thathitherto after the continued use of styptics and prolongedrest there remained to the family attendant no other coursebut that of hysterectomy as the last resource. No one couldapproach this operation with feelings of satisfaction until allother means had been given a fair trial. Within the lastfew years, however, a third course of procedure had beencoming to the front, that of treatment by the therapeuticuse of X rays. Although many technical considerationsintervened relative to bulk, depth, and dosage, they wouldappear to have crystallised into two main schemes of treat-ment, the French scheme brought into existence andelaborated by Dr. Bordier of Lyons, more particularly; andthe German scheme elaborated by Albers Schönberg ofHamburg, and Gauss of Freiburg, and others. Looking atthis form of treatment by X rays from the point of view ofthe family practitioner, it should be noted that the

patient might be up and about, as far as haemorrhagewould allow, if that was a prominent symptom. The patientshould have a sitting every day or every other day fornine sittings. These nine sittings constituted a cycle. Itwas wise to allow 21 days to elapse, when a second cycleshould be given. This might be repeated five or even six

times, but it was rarely necessary to exceed this number ofcycles, for the treatment seemed to be cumulative, andshrinking seemed to go on after the treatment was left off.The sittings were conducted so that the uterus and tumourreceived a dose of X rays of about one to two milliamperes ;at the second sitting the right ovary was treated ; at the thirdthe left ; at the fourth the uterus and tumour again ; and soon. In particular cases the patient might be turned on her

’

face and hands, and the posterior aspect of the tumour, similarly treated through the sacrum and sciatic notches.’

Under this system an artificial menopause was brought’

about, and the patients suffered from flushings, whilst thetumour notably shrank in size, but not always to disappear-ance, whilst haemorrhage was abolished, and the patientsexpressed themselves as feeling better. The German systemdid not differ in principle from the French, but their

tendency seemed to be to give the heaviest possible dosefrom multiple cross-fire directions for a few days or even hourswith a long interval of rest when the course was repeated.

1 In each form of treatment careful filtering of each dose iscarried out with 2 mm. to 3 mm. of aluminium. The notes

’ of four cases were read, in each of which notable improve-

1 ment had occurred, and artificial menopauses established.

with the usual climacteric symptoms of flu,hings, with1 shrinking of the tumour. Thus one case, 39 years of

E age, commenced treatment in August, 1912. In May, 1913,1 she was able to undertake all her household duties, looking and feeling quite well. Another case commenced treatment

in October, 1912, and in December slight haemorrhage, occurred, but none after. She was able to attend to her

l household duties after the fifth cycle. In a third case a

I woman of 43 was similarly treated. It was commenced in

September, 1912, and in April, 1913, it was noted that theb menopause was complete for four months. It had com-

menced in the third cycle. In July, at the end of the fourthL cycle, she had a period lasting 36 hours only. In the fourth

b case a woman of 49 had a fairly large fibroma occupying ther position of a seven months’ infant. Although, as in all theg other cases, hsemorrhage was a marked feature, it ceased

during the first cycle and did not return. In each of these

r cases the appearance of exsanguination gradually changingb to that of health was most satisfactory., Dr. F. A. ROPER reported the case of a widow, aged 42,suffering from a somewhat rapidly growing fibromyoma.

3

896

uteri. The chief symptom complained of was pain at themonthly periods, so severe that she was prostrated for fourdays at every period, and no doubt partly resulting from thisshe was in an exceedingly neurotic state. The fibroid wasestimated to be larger than a croquet ball. Treatment wascommenced on May 9th, 1913, on the lines of the Hamburgschool, series of five irradiations through five portals of

°entry-two behind and three on the abdomen-being givenon successive days, a clear fortnight elapsing between eachseries. Seven series were given, a filter of 2 mm. aluminiumbeing used. A sitting comprised five to ten minutes with- current 3 to 6 ma. After one normal and two scanty periodssix months’ amenorrhoea resulted, with complete relief ofpain, and shrinkage and sclerosis of the tumour to the size ofa tangerine orange. Menopausal symptoms appeared whichwere relieved on the reappearance of the menstrual flow,which was unaccompanied by pain. There was no trace ofdermatitis save slight browning. Comparing this method withthat of Professor Gauss, Dr. Roper preferred it on account ofthe fact that the results were in every way as good as thoseof Gauss. The excessive doses given by the Freiburg schoolwere, therefore, unnecessary.

In the discussion which followed the reading of these twopapers Mr. F. W. LANGRIDGE remarked on the resemblance

between the uterus and the prostate gland, and asked thereaders of the papers whether they had extended thetreatment to cases of prostatic enlargement.

Dr. GORDON considered that Dr. Harris was a pioneer inEngland as regards this treatment, and related a case wheremitral stenosis in conjunction with fibromyomata made. the operation undertaken for the latter to be fraught withthe gravest anxiety. He asked the reason why Bordierconsidered those cases which have ceased to menstruateunsuitable for treatment.

Mr. C. E. W. BELL alluded to the method of Apostoli whereglowing accounts were at first published, although nothingwas now heard of this treatment.

Mr. A. L. CANDLER advised that women aged 40 andupwards suffering from fibromyomata, who were blanchedfrom haemorrhage, should be treated by X rays, and lateron have the fibroids removed to guard against possiblemalignancy in the future. He regarded the X ray treatmentas a preliminary to operation.

Dr. R. V. SOLLY stated that tumours of the prostate were. frequently composed largely of adenomatous tissue which

would be affected by X rays to a very slight extent.Mr. A. C. ROPER, speaking from the surgeon’s point of

view, expressed the relief he would feel when freed from theoverwhelming responsibility of doing serious operations oncases weakened and depoverished by hemorrhage. Theadvantages of X ray treatment were: (1) saves risk of opera-tion ; (2) saves necessary rest of six months after operation ;(3) the course of six months’ treatment less costly, no

nursing required, no absolute rest in bed, no risk, andsteady improvement. He considered the German methodto be most convenient where sittings follow daily.

Dr. HARRIS, in his reply, stated that X rays had abeneficial effect on the enlarged prostate, and that zincionic treatment through the rectum had also proved useful.Apostoli’s method was merely a form of ionisation offibroids.

Dr. R. EAGER reported a case of Aneurysm of the LeftVentricle bursting into the pericardium. There was muchatheroma of the aorta. He also showed the heart and aortaof a case where rupture of the aorta had taken place into thepericardial sac. There was a specific history in this case.

EDINBURGH OBSTETRICAL SOCIETY.

-Etiology of Eclanapsia.-The Registration of Stillbirths.A MEETING of this society was held on March llth, Sir

J. HALLIDAY CROOM, the President, being in the chair.Dr. JAMES YOUNG, in a paper and epidiascopic demonstra-

tion, discussed the Etiology of Eclampsia. He referred tothe well-recognised fact that albuminuria and eclampsia wereespecially apt to be associated with red infarcts in the

placenta. As, however, eclampsia was found with an

apparently healthy placenta, and no toxaemia where therewas definite infarction, the association remained somewhatof a mystery. It was usually believed that the infarctionwas merely to be looked upon as an accompaniment or as a

result. Dr. Young showed from many points of view thatinfarction was due to involvement of the maternal vessels andnot to disease of the fcetal vessels. It had long been knownthat the chorionio elements could live where there was nofoetal circulation-e.g., in the early trophoblast, in hydatidmole, and in chorion epithelioma. In accidental haemorrhage,which was known to be especially associated with albu-minuria and eclampsia, he showed evidence of placentaldisease in apparently healthy placentas. This diseasewould only be possible where a certain time had elapsedbetween the haemorrhage and the removal of the placenta.In this way it was possible to explain the fact that in only50 per cent. of the cases was there a toxaemia. Dr. Youngreferred to experimental proof of his thesis that the

placenta was the source of the poison. He had isolated asubstance from healthy placentm, which had been appro-priately treated, that induced severe convulsions in animalsand, in addition, focal necrosis in the liver, a change thatwas recognised to be especially characteristic of eclampsia.-The PRESIDENT stated that he had learned a great deal.The villus if cut off entirely from the foetal supply could livein healthy maternal blood. Dr. Young had shown thatinfarcts were surrounded by blood clots and had also shownthat these blood clots pressed upon the surrounding parts ofthe placental tissue, and by so doing destroyed its vitality.This degenerated part of the placenta was the source of thetoxin which caused eclampsia. That point of view had notbeen presented before. If it be that this toxin was the cause,then Dr. Young had proved his case, because he had shownthat he could produce very similar changes in animals. Ifthis were so, a very great advance had been made in thedemonstration of the cause of eclampsia. It was, however,a mystery still. With regard to accidental haemorrhage, hewas not so sure that only 50 per cent. were associatedwith albuminuria.-Dr. D. BERRY HART asked wherethe toxins came from in the infarct. The toxins werein the blood and also the tissue. The toxin was

deposited in the clotted blood before the infarct took place.He did not think that Dr. Young could say that theseinfarcts were the cause of the eclampsia ; if that were so theyshould at once deliver the women and remove the placenta.-Dr. W. FORDYCE said that in eclampsia certain changesoccurred in the liver and kidneys, and he thought Dr. Younghad brought no proof to show that the poison was from theplacenta any more than from the liver and kidneys.-Dr.R. W. JOHNSTONE asked how Dr. Young applied his theoryto the cases where eclampsia occurred after delivery.-Dr.H. OLIPHANT NICHOLSON, Dr. J. W. BALLANTYNE, and Dr.A. C. GUTHRIE discussed the paper.-Dr. YOUNG, in his

reply, stated that in the experiments he employed healthyplacentas specially treated to reproduce the diseased con-dition.

Dr. BALLAN’rYNE read a paper on the Registration ofStillbirths. He said that the first difficulty was one ofdefinition. Notification was giving notice or making intima-tion ; registration implied declaration and inscription. TheNotification of Births Act of 1907 required notice within36 hours ; registration within 42 days. The Notification ofBirths Act had been adopted only in 316 out of the 1822Local Government areas in England and Wales ; but theseareas represented 18,000,000 persons out of a total populationof 36,000,000. The persons upon whom the duty of declaringthe birth was laid differed in the two cases. The Notifica-tion of Births Act went further than the Registration ofBirths Act of 1874, by calling for declaration of birthwith respect to children born alive and to those borndead after 28 weeks’ gestation. This involved, therefore,registration of a certain number of stillbirths. Byfar the most valuable contribution which had been madeto the proper understanding of stillbirths and their registra-tion of recent years was that contained in the Reportof the Special Committee of the Royal Statistical Society onInfantile Mortality of December, 1912. The committeereceived replies from 103 registration officers all over the

I world. The registration of stillbirths was not compulsory! in Great Britain and in certain of her dependencies, in Denmark, and in a few of the individual, States of theUnited States of America. Numerous countries had com-! pulsory registration of stillbirths ; Great Britain and Ireland; had been singularly dilatory in taking steps to acquireLpowers to discover the stillbirth rate in the population.6The Statistical Society’s committee stated that, as far as