1744

WEST LONDON MEDICO-CHIRURGICALSOCIETY.

The Laboratory Diagnosis of Syphilis.A MEETING of this society was held on Dec. 3rd, Dr.

NEVILLE T. WOOD, the President, being in the chair.Mr. HUGH W. BAYLY read a paper on " Laboratory

Methods for the Diagnosis of Syphilis." In Part I., SerumDiagnosis, he discussed the technique and rationale of theWassermann and Bordet-Gengou reactions and described theterms commonly employed. Part II. Micro-biology.—Theultra-microscope, or reflecting immersion condenser, and thetechnique for its use were described. It was stated that the

treponema pallidum can be demonstrated in practicallyevery early untreated chancre and is also found in papularrash and mucous plaques. It appears as an extremely finespiral from 5-25,u long, with very regular and closelyset spirals. Number of spirals range from 5-25. Dis-tilled water is the best medium in which to examinethem. Giant forms may be seen when examinedin serum, and in this medium the movements are moreactive and last longer than in water. The movements con-sist of bending, snake-like movements, local wave con-

traction. Viscosity develops as organism becomes lessmotile. Agglutination occurs in serum only. The older theinfection the greater the tendency to clump (auto-agglutina-tion). Diagrams were shown for differential diagnosis of

"spirochasta refringens," "spirochseta, balanitidis," &c.Part III. Inoculation experiments.-Path of infection andmode of entrance discussed ; small superficial erosions themost dangerous. Incubation : The more resistant the animalthe shorter the incubation period. In apes positiveinoculation obtained with material from the bone-marrow,spleen, and, much less frequently, testicle and lymphaticglands. In man : Positive inoculation obtained from well-marked secondary syphilis. F:s: Attenuated by passagethrough apes. Prophylactic measures discussed. Conclusions:(1) That syphilitic infection is easily preventable ; (2) thatsuch infection can be diagnosed with certainty on the firstappearance of a primary sore by means of the micro-

scope ; (3) that the earlier that the treatment is begun thebetter for the patient ; (4) that a positive Wassermann, in theabsence of a few diseases, is pathognomonic of syphilis;(5) that the Wassermann reaction forms a very useful guideto treatment, and that antisyphilitic treatment should becontinued till a succession of negative results are obtained ;(6) that the blood should be examined every six months fora couple of years at least after the first negative reaction isrecorded.

Colonel F. J. LAMBKIN, R.A.M.C., said that for a year allthe syphilitic cases admitted in the Rochester Row Hospitalhad been subjected to Wassermann’s reaction. He quiteagreed as to the value both for the treatment and diagnosisand quoted cases. He mentioned that the cases treated witharylarsenates had shown no toxic symptoms.

Captain HARRISON, R.A.M.C., had carried out the test inRochester Row Hospital and confirmed all that ColonelLambkin had said. He hoped that much might be learntand done for the treatment, &c., of syphilis by the use ofthe Wassermann test in the army on account of the efficient

system of supervision which is required in these cases. He

thought it advisable in the case of negative reaction to repeatthe test with untreated patients’ serum.

Mr. J. ERNEST LANE said that he agreed with the value ofWassermann’s test. It would allow early treatment and atthe same time avoid the treatment of non-syphilitics withprolonged courses of mercury, which had undoubtedlyoccurred. He spoke as to the toxic effects of the aryl-arsenates.

Mr. C. GiBBS agreed with the great advance in syphilo-logy due to Wassermann’s reaction. He also spoke on thearylarsenate question.

Mr. REGINALD H. HAYES hoped that the test would settlethe relative values of the modes of administering mercury.

Mr. J. E. R. McDoNAGH said that there was a tendencyfor the test to be negative in undoubted syphilitic cases

whilst taking mercury. He pointed out the great use of thetest in women who aborted. He had found a tendency forthe test to remain permanently positive in the cases of

children suffering from congenital syphilis, however longthey were treated with mercury. He mentioned some causesof failure of the test and how to remedy them.

Dr. F. E. BATTEN spoke and Mr. BAYLY replied.

EDINBURGH MEDICO-CHIRURGICALSOCIETY.

Exhibition of Cases.-Therccwe4t-ics of Raditbm.-IJ?J8pepsia, and Early Ticbere2losis in Children.

A MEETING of this society was held on Dec. 1st, Dr.BYROM BRAMWELL, the President, being in the chair.The PRESIDENT exhibited a man, unmarried, aged 32:

years, who suffered from Preataxic Tabes. The case was

both of theoretical and practical interest as these tabeticattacks of gastric and intestinal crises were often mistakenin practice for other diseases. The man had been operatedon for appendicitis two years ago, and since then he affirmedhe had been subject to very severe attacks of abdominal]pain. On examination nothing abnormal could be made outin the abdomen and it was at first thought that the attackswere due to post-operative adhesions. On further inquiry,however, it was discovered that the man had suffered fromsimilar attacks for six months previous to his operation. Hehad never had lightning pains or ataxia, but his knee andAchilles jerks were completely absent; the Argyll-Robertsonphenomenon was present. His blood showed marked lympho-cytosis (400 in each field) and the Wassermann test waspresent. He admitted having contracted syphilis nine yearsago. The attacks, which were very severe, occurred aboutonce in six weeks and were accompanied by tenesmus. Hewas being treated by X rays and the patient felt himself tobe better.

Mr. A. A. SCOT SKIRVINC, showed a man who illus-trated certain Defects of Memory after operation forMiddle Meningeal Hoemorrhage. The patient fell down-stairs five months ago and was unconscious when

admitted to the infirmary. On examination there were no

symptoms of compression, the pupils were equal, and

paralysis was absent. One hour later, however, it was

found that there was right-sided paralysis and the left

pupil was double the size of the right. Haemorrhage fromthe left middle meningeal artery was diagnosed. At the

operation a fairly large clot was removed. By next day theparalysis had gone, but the patient remained perfectly un-conscious for nearly three weeks. He then began to recover,but for many months subsequently marked weakness in theright arm and hand remained with slurring of the speech,especially in words with the letter " s," and loss of memory.He was formerly a clerk, but could not perform simple sumsfor nearly 18 months after his accident. At present he hasgreatly improved and his mental faculties and speech werereturning.

Dr. FRANCIS D. BOYD exhibited a man to illustrate thebenefit of a Salt-free Diet in certain forms of (Edema. The

patient suffered from a syphilitic ulcer on the forehead.When admitted to the ward he was perfectly waterloggedand the cedema extended up to the shoulder-blades. Theexcretion of urine was very scanty, and especially thechloride excretion. He was put on a varied diet (meat, eggs,

&c.) but one free from sodium chloride, and immediatelythere was an enormous diuresis with great loss in weight.He was discharged almost well, but on resuming his ordinarydiet his diseased condition soon returned. On placing himagain on salt-free food he rapidly improved and was atpresent perfectly well.

Professor H. ALEXIS THOMSON exhibited a boy, aged 11years, in whom, on account of a Periosteal Sarcoma of theRight Humerus, the middle third of the shaft was resected anda portion of the fibula inserted in its place. Formerly the onlytreatment for such a disease was amputation, but the historyalmost always was that the patient died from recurrence.At first excision was only employed for the less malignantforms, but it seemed only right to give the boy the chance ofrecovery in this case. The operation was performed threemonths ago. The tumour, with 3 inches of boae, was resected,and those parts of the muscle which were infiltrated were ,

also removed. Unfortunately the musculo-spiral nerve was ’

sacrificed. About 5 inches of the boy’s left fibula, togetherwith its periosteum, was excised, and the ends having been

1745

sharpened they were jammed into the cut ends of tthumerus. The wounds were quite healed and there seemeto be firm union between the bones. The cut ends of th

musculo-spiral nerve were spliced into the musculo-cutaneornerve and restoration of function was hoped for. Trealment by X rays was being carried out in order to preverrecurrence of the growth if possible.

Dr. JAMES RITCHIE, jun., gave a demonstration c

Wassermann’s reaction.Dr. DAWSON TURNER read a paper on the Use and Effect

of Radium, and illustrated it by patients and lantern slidesThe paper will be published in a future number c

THE LANCET.Dr. A. DINGWALL FORDYCE read a paper on the Differ

ential Diagnosis and Treatment of a common form o

Dyspepsia and of Early Tuberculous Infection in Childrenin the course of which he said: The introduction within recen

years of new methods and new tests has conduced to greateprecision in diagnosis, and, through the recognition an<

differentiation of various conditions in their early stages, habeen of value in rendering possible early active treatmentThere is considerable difficulty in certain cases in childreiin ascertaining whether the symptom-complex is due to Ichronic digestive or metabolic disorder, or whether a chroni(infective condition-e.g., tubercle-lies at the root of th<evil. The cases here considered are marked by vagueness in personal history and in symptoms, all havE

very chronic symptoms, mostly gastro-intestinal, therEare no definite abnormal physical signs, and the childrerare going about, are comparatively well, and have approxi.mately normal temperatures. Accurate and prompt dia.

gnosis is essential to permit of active treatment. Thf

special points in the diagnosis are: 1. The capacity oj

digesting fat. This capacity is considerable in cases oj

early tuberculous infection whereas it is markedly diminishedin dyspepsia. 2. The reaction to tuberculin tests. Von

Pirquet’s cutaneous tuberculin reaction is of great valuein diagnosing cases of this kind. A positive reactionto either the human or bovine form of tuberculin isa call for active antitubercular treatment. 3. The quanti-tative and qualitative estimation of the sulphates in theurine. 4. The opsonic index. Most of the tuberculouscases of which I speak are those of glandular tuberculosis.The treatment in the two classes of cases varies considerably:in chronic dyspepsia, markedly reduced diet, &c.; in earlytubercle infection, free diet, fresh air, the prevention ofsources of glandular irritation and infection, and tuberculin.My own impressions as regards the administration of tuber-culin in obviously glandular infections-mainly abdominal orcervical glands--or in cases which by the previous methodsof diagnosis I have diagnosed as latent tuberculosis, and Ithink these are chiefly glandular, are : 1. That this treat-ment is very unsafe when large doses are employed or whenthe temperature is unsteady. 2. That it is quite safein the minute doses hereafter mentioned, when com-

menced with a practically normal temperature andwhen the patient is kept under observation. 3. Thatin many cases tuberculin treatment appears to have nodefinite effect upon the condition one way or another.4. That in cases in which treatment by rest, climate, feeding,and careful nursing can be employed, improvement by thesemeans alone is usually so marked that it is impossible toattribute to tuberculin, when given in these cases, its duemeed of praise or to judge whether it takes any part what-ever in the improvement. 5. That, however, when treat-ment by rest, climate, feeding, and careful nursing cannot beproperly adopted, tuberculin is often of very marked value.These are the cases which otherwise do badly, and tuberculintreatment is, with them, of the greatest importance. 6. ThatT.R. is, as a rule, preferable to P.T.R. 7. That for routine euse the method of hypodermic injection is greatly superiorto that of oral administration-the effect of giving tuber-culin by the mouth varies very much. These impressionsare derived from the treatment of about 100 cases

during the past three years. At the commencementI used the opsonic index as a guide, but early foundit impossible and, I think, unnecessary to take theindex in selected cases such as these. The condition ofthe temperature is, I think, a sufficient guide for theinitial administration and the clinical symptoms thereafterin relation to each injection. The forms of tuberculin Ihave used have been Koch’s new tuberculin, T.R., and the

jhe corresponding bovine tuberculin, P. T. R. The two varietiesled I originally employed in order to determine their varying

results in cases showing different reactions to von Pirquet’s)us test with human and bovine tuberculin. I have come to theat- conclusion, however, that, no matter to which strain ofmt bacillus von Pirquet’s reaction is positive, T. R. is the

tuberculin of the greater therapeutic value. The tuber-of culin was given hypodermically and by the mouth. By

the mouth the doses I gave varied from 1-1000th of a

milligramme to l-250th of a milligramme and the resultses. I considered very disappointing; only very occasionallyof was any satisfactory result noticeable. By hypodermic

injection the initial dose varied from 1-10000th of a milli-r- gramme to an infant 9 months old, to l-3000th of a milli-of gramme to a child aged 12 years. The injections were re-!n, peated weekly or fortnightly, and the dose increased at longnt intervals and by very minute amounts, the rapidity and;er amount of increase desirable being gauged by the clinicalnd condition. In all cases diminished vitality or health-appa-as rent in any manner whatever-during the few days followingit. an injection was considered a sign, either to diminish thean dose or increase the intervals between doses, the conditionsa aimed at being that after each injection the child shouldic continue steady improvement or show a step in advance. In1e several instances a child while under tuberculin treatmente- had apparently attained sound health ; the tuberculin treat-ve ment was stopped for two or three months, the child relapsed,re only again to improve on the renewal of the injections.-;n Dr. JOHN W. SIMPSON thought that it was almost impossible:i- to diagnose chronic intestinal catarrh from tuberculosis of thea- intestine in children and was of opinion that reaction to the

tuberculin test was not of very much value because it couldbe obtained in perfectly healthy children.-Dr. D. CHALMERSWATSON said that the same difficulty in diagnosis existed in

d young adults as in children. He drew attention to the valuem of thyroid in tuberculous cases.-Dr. J. S. FOWLER and Dr.

BOYD also took part in the discussion.m

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ROYAL ACADEMY OF MEDICINE INIRELAND.

SECTION OF SURGERY.

Operative Treatment of Fracture.A MEETING of this section was held on Nov. 19tb, Mr.

JOHN LENTAIGNE, the President, being in the chair.The PRESIDENT, in his introductory remarks, commented

on the falling off in the attendances at the meetings,although during the past session many valuable papers hadbeen read and many cases of extreme interest had beenexhibited.

Mr. R. LANE JOYNT read a paper on the OperativeTreatment of Fracture. He said that X ray examinationof united fractures of the femur which had been treated bythe common methods showed in many cases an amount of

deformity which was little short of that seen in a number ofmuseum specimens which were formerly regarded as examplesof mal-union. The functional result in most of these caseswas very bad. The only way in which shortening could beprevented and the fragments got into perfect line was byoperation. Even when complete asepsis was not obtainedsuppuration was usually slight, and the results were muchbetter than when the older methods were employed. A

striking feature after the fixation of the fragments was therapid disappearance of pain. He then described minutelythe details of the operation for wiring, and of that in whichLane’s steel plates were used. He looked upon Parkhill’smethod as being superseded in some cases ; but there wereothers, notably where there was a compound fracture of thetibia with excessive suppuration and necrosed bone, in whichit would be folly to attempt to suture or screw with Lane’splates or to use wire.Mr. W. I. DE C. WHEELER read a paper on the Operative

Treatment of Fracture and showed four cases where simpletreatment had failed, but continuity and union were after-wards established by the use of screws and metal plates. Inone case the operation was performed 3-2L months after acompound fracture of the tibia and fibula which failed tounite, so that the limb was rendered useless. After operationcomplete union was obtained, the wound, which was partiallyopen, healing over six screws holding two plates. The