462

grasp anything new. They were intolerant of asepticmethods, and it could well be understood that oneyear’s training did not lead them far towardsacquiring the desired standard of work. After thistraining they were given a certificate written in alanguage which they did not understand testifyingto their efficiency in midwifery. With this certificatethey were well fortified to defend themselves. Dr.Nawal Kishore held that it was imperative to establishan efficient service for the teaching and training ofmidwives who should all be of a higher standard thanthose who had hitherto presented themselves. At thevery least they should have a reading and writingknowledge of their own vernacular. She begged thatmedical women who desired to render service to thesuffering women of India should use their influenceto raise the standard of efficiency in the training ofmidwives in that country.

’

Dr. V. PILLEY gave some account of the LadyHardinge Medical College and the organisation fortraining medical students.Dr. B. NATARAJAN commented on the good feelingbetween men and women medical students in India,and stressed the importance of employing Indianmedical women for work among Indian women.Sometimes European medical women attempted towork among the people without having studied theirlanguage, and naturally they could not gain theconfidence of their patients.

Mrs. RAMA RAO spoke from the point of view ofa social worker. She appealed for the formation ofsome scheme which could be considered and supportedby the All-India Women’s Conference. The greatthing was the teaching of sanitary conditions invillages and the training of more dais for maternitywork in outlying districts. These dais worked fora wage of a pound per month, and the immediateprovision of many trained dais would be of greaterbenefit to the women of India than the slow organisa-tion of a highly efficient service. In her view it wasimportant to keep the indigenous dais, even if theyhad to have a two years’ training instead of one.This hereditary profession was a factor of life in Indiawhich could not be ignored, and no efforts must bespared to make it efficient.

-RepZy.Lady BARRETT pointed out that the proper training

of midwives depended on an efficient maternityhospital, staffed by expert medical women, wheremidwives could see labours conducted under goodconditions. It also implied a service of medicalwomen who could show them how to adapt theirtraining by midwifery work in the patient’s own home.It was for this reason that she considered that thebest method of advance was by the appointment ofmedical women to the provincial governments asdirectors of maternity and child welfare.

LIVERPOOL MEDICAL INSTITUTION.

AT a meeting of this Institution on Feb. 13th Mr.C. THURSTAN HOLLAND and Dr. J. M. W. MORISON(Edinburgh) opened a discussion onRadium in the Treatment of Malignant Disease.Mr. HOLLAND began by saying that radium never

had been and never would be the cure for cancer.Radium, like the knife and diathermy, was essentiallya local remedy and ro merely local attack could everbe entirely successful. Methods of raising money hadunfortunately led the public to believe that, givenenough radium, cancer need no longer be feared. Thepublished statistics were unreliable in estimating thereal results. The term " cure " should not be appliedto the so-called five years’ cure ; in the large majorityof cases the mere removal of a tumour was not enough,a general infection had already taken place, and it wasmerely a matter of time before some kind of protectiongave way and recurrence or metastases followed.Considerably over half the yearly deaths from cancer

: were from disease of the gastro-intestinal tract and, its appendages, and this could not be a very hopeful: field for radium treatment.

Dr. MORISON said that the National Radium, Commission did not regard the question of the use of, radium in the treatment of cancer as one that was

settled, but rather that the subject was one whichcalled for careful inquiry. The trend of radiumtherapy in the great continental centres, he thought,was the avoidance, whenever possible, of the directintroduction into the tissues of tubes and needles,the line of advance being the development of thesurface applicator, designed in such a way that thedistribution of tubes and needles on the outer surfacegave what was for all practical purposes uniformirradiation of the skin surface. He regarded the workof Murdoch and Stahel at I’H6pital Burgmann inBrussels as a genuine advance. Radium therapy wasstill in the experimental stage, but the results obtainedjustified its use and justified further research, bothclinical and experimental.Mr. G. C. E. SIMPSON thought the openers had

taken far too pessimistic a view, that the experienceof surgeons in the diagnosis of cancer and of theresults which might be obtained in individual caseswas such that it should not be eliminated by intro-ducing a new class of specialist, the radiological experton cancer. While agreeing that in every centre thesurgeon should be able to seek the advice of suchexperts, he considered the surgeon was justified inusing radium if he had made himself familiar with theresults obtained and the treatment used in the greatsurgical clinics which had advanced radium treatmentin recent years. Such treatment in operable caseshad the advantage of saving mutilating operations,and there were many places, such as the floor of themouth, where radical surgery of cancer was not onlyhighly dangerous but almost hopeless and whereradium treatment gave at least great ease and in manycases apparent cure. After all, whatever the dangersof inexperienced treatment, cancer itself was a fataldisease.Mr. F. STRONG HEANEY held that Mr. Holland

had proved his thesis that radium was not " the cure "for cancer, but surgeons and gynaecologists had reallynot an exaggerated or false idea of the value of theremedy. Under the present voluntary hospital regimeappeals for funds must be made by laymen, and were,in fact, made without reference to medical men. Theprofession itself was fully aware of the limitationsof this very valuable weapon in treating cancer.

Objection had been taken to the five years’ standardof non-recurrence, but the only way to compareresults was to adopt some standard of comparison,be it five years or otherwise. Cases must be selectedby someone in a position to judge the possibilities ofsurgery. The collaboration of the radiologist and thephysicist was, of course, indispensable. Whether inthe hands of surgeons or radiologists methods werestill largely empirical. As between radium and deeptherapy radium would be preferred until more andbetter results from deep therapy were recorded.

Dr. RAWDON SMITH, whilst agreeing that certain ofthe methods for raising money were much to bedeprecated, hoped that nothing Mr. Holland hadsaid would prevent the public subscribing for radiumin Liverpool, where both research and radiotherapywere behindhand.

Mr. PHILIP HAwE said the estimation of the dosageof radium in terms of ergs, although ideal, seemed toprevent many difficulties. In the case of superficialtumours it was a time-consuming calculation, but withdeep tumours whose size could not be accurately deter-mined it did not appear of much value to him. Thebomb treatment was justifiable only in the mostexpert hands and as even then it was both dangerousand of doubtful value it was unlikely that it wouldever come into more general use. Mr. Hawe had beenmuch impressed during a visit to Brussels by theimportance of having at one’s disposal for the treat-ment of malignant disease all three methods-radium,surgery, and X rays-if the best results were to be

463

obtained. For instance, carcinoma of the rectum wasprobably best dealt with by a preliminary colostomy,then radium after eight days and in two months’ timea perineal resection (Newman and Coryn). The resultswere better than those of surgery alone and far betterthan could be hoped for with radium alone. Operablebreast cases were dealt with by a preliminary course ofX ray therapy, then operation on the usual lines, andfinally another course of X rays. In inoperable casesand superficial recurrences radium was used, and forthe deep recurrences X rays were used. With extensiveirradiation regular blood examination was of greatimportance ; leucopenia was a danger signal.

Prof. W. J. DILLING said that from personal know-ledge of beneficial results at the Radium Institutein Paris he was convinced that further supplies ofradium were necessary in Liverpool in order thatpatients might not be denied the relief and benefitwhich this therapeutic agent could afford in certaintypes of malignant disease. In Liverpool, with itscomplexity of hospitals, he felt that the ideal systemfor the effective utilisation of radium was the establish-ment, under the supervision of the University, of aradium institute where a directing medical officer,specially trained in the physics and modern techniqueof both X ray and radium therapy, could guidesurgeons as to the dosage and methods most promisingof success and could organise research with a view ofimproving technique an results. The present policyof the Radium Commission to lend radium to only onehospital in an area was not, in his opinion, designedto facilitate th.3 use of this therapeutic agent for themost deserving and appropriate cases.

Dr. C. 0. STALLYBRASS inquired what was the bestway of securing the cooperation of the surgeon andthe radiologist and whether the Radium Commissionwere taking any steps to place the training of radio-logists in the treatment of cancer on a sound basis. I

Mr. FRANK JEANS said he did not consider Mr. ,Holland and Dr. Morison pessimists. They were ’,simply telling the truth-that the treatment by radium ’,or by surgery was productive of equally good or bad ’,,results. Radium had not yet supplanted surgery.Naturally patients preferred radium, but the position ’,was that there was a great deal of cancer and verylittle radium and surgeons were forced to operatenearly as much as ever. The extravagant claims forradium were perhaps (but he did not admit this)partly pardonable because it was known that thepublic would not subscribe for research, but wouldfor a promise of cure.

Mr. HOLLAND and Dr. MORISON replied.Protrusion of the Mandible.

Mr. G. C. E. SIMPSON and Mr. H. G. WATKINdescribed a case of protrusion of the mandible in aman of 28. His lower teeth were 19 mm. anterior tothe upper and he was unable to eat well and ashamedto eat in public. The condition, they said, is in somecases congenital and in others caused by finger suckingor early loss of temporary incisors-leading to the lowerteeth getting too far forward. Once started it tendsto increase from mechanical causes unless checked anddental measures are most valuable before the loss ofthe deciduous molars. Angle and Whipple havedevised an operation of division of the mandible onboth sides at about the level of the premolar teeth, butthere are objections to it-namely, first the injury tothe inferior dental nerve in the canal and its effect onthe front teeth, and secondly the probability of sepsis.Bruhn, of Düsseldorf (as a result of cooperation ofdental surgeon and surgeon in military orthopaedicsurgery), relieved the condition by resection of themandible below the notch but above the inferiordental foramen by a subcutaneous osteotomy, andthis operation has also been performed by Babcock inPhiladelphia. In the case reported this method waschosen and Mr. Watkin first fitted cap splints to thejaws, packing the splint to lever the jaw into the bestposition as studied on models of the patient’s bite, andthe osteotomy was performed. After six weeks in the

splints it was found that the upper posterior molarslocked the bite and that the incisors did not meet.After extraction of these teeth and grinding down ofsome posterior teeth which had never met and beenworn to the pattern of their opponents the patientwas left with sixteen teeth in good occlusion. The

patient was now able to eat satisfactorily. Photo-graphs and models were shown and emphasis was laidon the advantage of the surgeon and dental surgeonco8perating from the start in deformities and fracturesof the jaws.

HARVEIAN SOCIETY.

STREPTOCOCCAL INFECTIONS.

A MEETING of this Society was held at PaddingtonTown Hall on Feb. 20th, with Dr. P. MONTAGUE SMITH,the President, in the chair.-Dr. C. BRUCE PERRYread the Buckston Browne Prize Essay. The problemof the streptococcus as a causal factor in disease, hesaid, had not yet been satisfactorily solved, and it wasimpossible to say whether the multifarious illnessesconnected with streptococcal infection were entirelystrain-specific or not. The recent work of Birkhaugand Small gave further support to the hyperergyhypothesis according to which a sensitised personwas liable to react briskly to further doses of strepto-coccal infection. Dr. Perry thought the portal ofentry, the condition of the patient, and the series ofillnesses to which this individual had been previouslysubject played a large part in determining what type,if any, of chronic streptococcal illness he was likelyto develop. Further research work could be moresatisfactorily directed to the consideration of thepatient’s condition than to the identification anddifferentiation of the various types of streptococci.Focal sepsis itself did not seem to play a large part inthis type of illness. There was no proof, even if a,

patient did recover after the removal of the focus,that such was the primary cause ; for in all probabilitythe improvement was due to the general improvementin the patient’s resistance. Consequently, it wasmore important to consider his metabolic type, theillnesses from which he had previously suffered, andthe way in which he reacted rather than to con-centrate upon the type of organism with which hewas infected.

Dr. R. CovE-SMiTH said he was entirely in agreementwith Dr. Perry about the importance of the individualas compared with that of the organism. Absorptionof toxic products lowered the resistance of the patient,thus leading to spread of local infection and involve-ment of other organs of the body. As a result ofthis spread from the primary focus, secondary lodge-ment might occur, and it was at this stage that focalsepsis became important; for where previoussensitisation had taken place, widespread resultsmight follow. The work of Parish and Okell suggestedthat the various streptococcal infections were dueessentially to the same species of bacteria. Thepathological effect varied with certain factors, mainlyquantitative, such as invasiveness and toxicity onthe part of the strain, and local or general susceptibilityon the part of the host. The chemical make-up andmetabolic pattern of the patient were of manifestimportance. Thus streptococcal infection which in anormal individual might give rise to a secondaryanaemia, would tend to produce pernicious anaemia inthose with defective bone-marrow, or subacuteseptic endocarditis in those with an incompleteendocardium and damaged heart valves. Apparentlythe main factors involved were : (1) The virulence ofthe organism. Haemolytic streptococci tended toproduce acute illness. (2) The amount of toxicabsorption. (3) The resistance of the patient. It wasupon this factor that the neutralisation of toxindepended. Consequently, endocrine deficiency,dietetic errors, disorders of metabolism and previousillness were of extreme importance in the developmentof chronic streptococcal illnesses.

I3