1124 NEWPORT MEDICAL SOCIETY. ture was never above 99° F. He injected alcohol into the superficial femoral. On the day following the injection the patient said she was more comfortable, and there was seen an opaque whitish band round the diseased area. Just previously to the injection the pain had been increasing. A week later the area which had been black was found to have recovered its normal colour, and the surface thermometer showed the diseased foot to be 2° warmer than the healthy one. The toes finally dropped off, and the illustration exhibited showed healthy-looking tissue; it had remained so. He had tried the same treatment in cases of Raynaud’s disease, and in Bürger’s disease, the condition which occurred in Polish Jews. He wondered whether the eating of rye bread had anything to do with the liability of these people to the disease. He thought there was a case to be made out for the occurrence of a spasmodic factor in senile gangrene, and the use of alcohol injection, even if it did not obviate amputa- tion, might enable it to be done safely lower down the limb. The PRESIDENT asked what could be done to stay gangrene when it was threatened. He quoted a case of his own in which, in a man aged 85, it supervened after influenza and pneumonia and pro- longed lying in bed. Perhaps some such method as citrating the blood could be employed. The patient referred to lost four of the toes off the affected foot, but he lived three years longer. Dr. PARKES WEBER spoke of premonitory symptoms of senile gangrene, such as intermittent claudication, and said Sampson Handley’s method seemed admirably adapted to preventing this disease. In intermittent claudication, when both lower extremities were ’, affected and there was nothing like erythromelalgia, the disease, he thought, was high up, either in the abdominal aorta or in the iliac arteries, and it was of the nature of atheroma, or atheroma with sclerosis. Mr. J. E. H. ROBERTS accepted Sir Anthony Bowlby’s definition of senile gangrene, and referred to the frequency with which calcification occurred at the bifurcation of the popliteal. He also spoke of the need for great care in handling the arteries, because of the great risk of cracking them. In thrombo-angeitis obliterans it must be remembered that the viscosity of the blood was considerably raised. Moreover, in most cases of senile gangrene there was a good deal of sugar in the urine, but after the gangrenous area was removed the sugar disappeared. If Mr. Sampson Handley’s operation was applicable, it was especially so when the premonitory symptoms occurred. Reply. Sir ANTHONY BowLBY congratulated Mr. Sampson Handley on the very successful case he had described and illustrated. But he thought that probably it was a case not of senile gangrene but of lodgment of an embolus in the femoral artery, especially as the onset was sudden and all the vessels there were pulseless. Still, whatever the cause, there was no I doubt the injection of alcohol was very beneficial. With regard to what could be done in the early stages to prevent an extension of the gangrene, he was still of the opinion that opium was far more beneficial than any other method he knew ; it improved the collateral circulation, and the patient felt the advan- tage of it for many months. With regard to the presence of sugar in the urine in these cases, he did not think it was sufficiently appreciated that in a large proportion of all the cases of senile gangrene there was a temporary glycosuria, and many such he had seen diagnosed as diabetic gangrene. Mostly it was a wrong diagnosis, and when operation- amputation or other--had been carried out, there was no longer glycosuria. These patients did not experience the characteristic thirst, nor the dry cracked tongue, nor did they pass the large quantities of urine which patients did with that disease. Of course, the prognosis in the non-diabetic cases was much better than in the diabetic. In the former class the condition of the tissues did not preclude amputa- tion. In the true diabetic cases with gangrene it was usually of the moist variety ; the patient had little or no resistance to the sepsis, and in the majority of cases the patient died before very long. He there- fore insisted that it was of great importance to draw a distinction between cases of gangrene in patients with diabetes, and those who merely had sugar in the urine as a concomitant of the local disease. MANCHESTER PATHOLOGICAL SOCIETY. A MEETING of this Society was held on Nov. 12th, when Prof. W. W. C. TOPLEY delivered his presidential address on Streptococci in Relation to Human Disease. He pointed out that streptococci must be regarded as the first amongst pathogenic organisms as a cause of death in man and particularly in association with affections of the respiratory tract. Classifi- cation of such organisms was difficult and any classification must necessarily be inaccurate. A classification suitable for ordinary purposes was suggested. The influence of secondary streptococcal infection in influenza and measles was emphasised, and stress was laid on the importance of isolation and careful nursing precautions to prevent the spread of pneumonia in these cases. The mass of clinical and experimental evidence, he said, was overwhelmingly in favour of scarlet fever being a primary streptococcal infection ; in the case of rheumatic fever, though the evidence was by no means so definite, there was much to support the view that a streptococcus was responsible. The pneumococcus group was considered, and Prof. Topley suggested that the Type I. antiserum appeared to be of definite therapeutic value. The decision as to the efficacy of pneumococcal antisera could only be arrived at by careful combined clinical and bacterio- logical investigation of a large number of eases. NEWPORT MEDICAL SOCIETY. AT the first clinical meeting of the session Mr. R. J. COLTLTER, the President, being in the chair, Dr. T. I. CANDY read a short communication on the Treatment by X Rays of Menorrhagia due to Uterine Fibroids. The type of case he considered best suited for this method of treatment was menorrhagia occurring in a patient over 40 years of age causing weakness and impairment of the general health and postponing the onset of the menopause. It was necessary to exclude the presence of malignancy and suppurative pelvic conditions. His technique was to administer at one sitting the dose necessary to produce amenorrhcea. The improved methods of measurement now available and the increase of knowledge of the biological action of X rays enabled this to be done with a considerable degree of precision. He found that the optimum time for treatment was within the first few days after cessation of menstruation. The next menstrual period came on as usual but always very much reduced in quantity. Thereafter complete amenorrhoea became established. In each of the 12 selected cases which he had treated the clinical results had been all that could be desired. In the discussion which followed Dr. GLYN MoRGAN, Dr. H. R. BURPITT, and Dr. MoRRELL THOMAS took part. Exhibition of Cases and specimen. Dr. MORRELL THOMAS showed an interesting patho- logical specimen of a case of haematometria following pregnancy. Dr. CABVBTH JOHNSON showed a case of aneurysm :)f the femoral artery associated with dilatation of the torta.
Transcript
1124 NEWPORT MEDICAL SOCIETY.
ture was never above 99° F. He injected alcoholinto the superficial femoral. On the day followingthe injection the patient said she was more comfortable,and there was seen an opaque whitish band roundthe diseased area. Just previously to the injectionthe pain had been increasing. A week later thearea which had been black was found to have recoveredits normal colour, and the surface thermometershowed the diseased foot to be 2° warmer thanthe healthy one. The toes finally dropped off, andthe illustration exhibited showed healthy-lookingtissue; it had remained so. He had tried the
same treatment in cases of Raynaud’s disease, andin Bürger’s disease, the condition which occurredin Polish Jews. He wondered whether the eatingof rye bread had anything to do with the liabilityof these people to the disease. He thought therewas a case to be made out for the occurrence of aspasmodic factor in senile gangrene, and the use ofalcohol injection, even if it did not obviate amputa-tion, might enable it to be done safely lower down thelimb.The PRESIDENT asked what could be done to
stay gangrene when it was threatened. He quoteda case of his own in which, in a man aged 85, itsupervened after influenza and pneumonia and pro-longed lying in bed. Perhaps some such methodas citrating the blood could be employed. Thepatient referred to lost four of the toes off the affectedfoot, but he lived three years longer.
Dr. PARKES WEBER spoke of premonitory symptomsof senile gangrene, such as intermittent claudication,and said Sampson Handley’s method seemed admirablyadapted to preventing this disease. In intermittentclaudication, when both lower extremities were ’,affected and there was nothing like erythromelalgia,the disease, he thought, was high up, either in theabdominal aorta or in the iliac arteries, and itwas of the nature of atheroma, or atheroma withsclerosis.
Mr. J. E. H. ROBERTS accepted Sir AnthonyBowlby’s definition of senile gangrene, and referredto the frequency with which calcification occurredat the bifurcation of the popliteal. He also spokeof the need for great care in handling the arteries,because of the great risk of cracking them. Inthrombo-angeitis obliterans it must be rememberedthat the viscosity of the blood was considerably raised.Moreover, in most cases of senile gangrene therewas a good deal of sugar in the urine, but after thegangrenous area was removed the sugar disappeared.If Mr. Sampson Handley’s operation was applicable,it was especially so when the premonitory symptomsoccurred.
Reply.Sir ANTHONY BowLBY congratulated Mr. Sampson
Handley on the very successful case he had describedand illustrated. But he thought that probably it was acase not of senile gangrene but of lodgment of anembolus in the femoral artery, especially as theonset was sudden and all the vessels there werepulseless. Still, whatever the cause, there was no Idoubt the injection of alcohol was very beneficial.With regard to what could be done in the early stagesto prevent an extension of the gangrene, he wasstill of the opinion that opium was far more beneficialthan any other method he knew ; it improved thecollateral circulation, and the patient felt the advan-tage of it for many months. With regard to the
presence of sugar in the urine in these cases, he didnot think it was sufficiently appreciated that in alarge proportion of all the cases of senile gangrenethere was a temporary glycosuria, and many suchhe had seen diagnosed as diabetic gangrene. Mostlyit was a wrong diagnosis, and when operation-amputation or other--had been carried out, therewas no longer glycosuria. These patients did notexperience the characteristic thirst, nor the drycracked tongue, nor did they pass the large quantitiesof urine which patients did with that disease. Ofcourse, the prognosis in the non-diabetic cases was
much better than in the diabetic. In the former classthe condition of the tissues did not preclude amputa-tion. In the true diabetic cases with gangrene itwas usually of the moist variety ; the patient hadlittle or no resistance to the sepsis, and in the majorityof cases the patient died before very long. He there-fore insisted that it was of great importance to drawa distinction between cases of gangrene in patientswith diabetes, and those who merely had sugar inthe urine as a concomitant of the local disease.
MANCHESTER PATHOLOGICAL SOCIETY.
A MEETING of this Society was held on Nov. 12th,when Prof. W. W. C. TOPLEY delivered his presidentialaddress on
Streptococci in Relation to Human Disease.He pointed out that streptococci must be regardedas the first amongst pathogenic organisms as a causeof death in man and particularly in associationwith affections of the respiratory tract. Classifi-cation of such organisms was difficult and anyclassification must necessarily be inaccurate. Aclassification suitable for ordinary purposes was
suggested. The influence of secondary streptococcalinfection in influenza and measles was emphasised,and stress was laid on the importance of isolationand careful nursing precautions to prevent thespread of pneumonia in these cases. The mass ofclinical and experimental evidence, he said, was
overwhelmingly in favour of scarlet fever being aprimary streptococcal infection ; in the case ofrheumatic fever, though the evidence was by nomeans so definite, there was much to support theview that a streptococcus was responsible. Thepneumococcus group was considered, and Prof.Topley suggested that the Type I. antiserum appearedto be of definite therapeutic value. The decision asto the efficacy of pneumococcal antisera could only bearrived at by careful combined clinical and bacterio-logical investigation of a large number of eases.
NEWPORT MEDICAL SOCIETY.
AT the first clinical meeting of the session Mr. R. J.COLTLTER, the President, being in the chair, Dr. T. I.CANDY read a short communication on the
Treatment by X Rays of Menorrhagia due to UterineFibroids.
The type of case he considered best suited for thismethod of treatment was menorrhagia occurring in apatient over 40 years of age causing weakness andimpairment of the general health and postponing theonset of the menopause. It was necessary to excludethe presence of malignancy and suppurative pelvicconditions. His technique was to administer at onesitting the dose necessary to produce amenorrhcea.The improved methods of measurement now availableand the increase of knowledge of the biological actionof X rays enabled this to be done with a considerabledegree of precision. He found that the optimum timefor treatment was within the first few days aftercessation of menstruation. The next menstrual periodcame on as usual but always very much reduced inquantity. Thereafter complete amenorrhoea becameestablished. In each of the 12 selected cases which hehad treated the clinical results had been all that couldbe desired.
In the discussion which followed Dr. GLYN MoRGAN,Dr. H. R. BURPITT, and Dr. MoRRELL THOMAS tookpart.
Exhibition of Cases and specimen.Dr. MORRELL THOMAS showed an interesting patho-
logical specimen of a case of haematometria followingpregnancy.Dr. CABVBTH JOHNSON showed a case of aneurysm
:)f the femoral artery associated with dilatation of thetorta.
1125EDINBURGH MEDICO-CHIRURGICAL SOCIETY.
Mr. R..J. LEE reported upon an interesting case of Isarcoma of the upper jaw in which the growth retro-gressed in a remarkable manner without treatmentbut which subsequently recurred. The diagnosis hadbeen confirmed by pathological examination.The PRESIDENT showed a small piece of fine copper
wire which he had removed from the vitreous of apatient who had been struck on the eye by a clod ofearth.
Dr. P. C. P. INGRAM showed a case of gumma of theupper lip successfully treated three years ago andwhich now showed, on X ray examination, extensivedeposits in both lungs. Physical signs were few and itwas thought to be a case of syphilis of the lungs.
EDINBURGH MEDICO-CHIRURGICALSOCIETY.
A MEETING of this Society was held on Nov. 5th.Sir DAVID WAI.T.ACE, the President, being in the chair.
Mr. A. H. H. SINCLAIR made a. communication on
Intraeapsular Fxtractio7t of Senile Catamct.The speaker began with a quotation from Mackenzie’stext-book of 1854, stating that there are three methods ifor the cure of cataract: 1. The removal of the icataract from the axis of vision. 2. The extractionof the cataract. 3. The division into fragments. Itwas pointed out that in the paper he wished to dealwith the extraction method, in the case of senilecataract only, and by the intracapsular method inwhich the lens is removed complete in its capsule.Historical facts were next given, including a descrip-tion,of Hermann Pagenstecher’s operations. The prin-cipal pioneer, he said, of the intracapsular methodin modern times was Colonel Henry Smith, who beganhis work at Jullundur, India, in 1895 by the capsulo-tomy method, but having seen the intracapsular Imethod performed by Malronez at Amritsar, becamea convert to the latter method. He developed theoperation on his own lines, iaow so well known, butstated then that the method was unsuited for juveniles.
Briefly the technique was as follows : A. largeincision was made with a Graefe’s knife, no atropinewas used and iridectomy might or might not beperformed. The lens was expressed by pressure onthe lower margin of the cornea by a blunt hook,either straight out or turning over in its deliveryaccording to how the pressure was applied. Com-menting on the method, Mr. Sinclair believed it tobe the best in many cases, but it had to be used withgreat care in this country, as in many cases the zonulewas very strong. A further method was described:to avoid strong pressure the extraction of the lensin its capsule effected by the application of a smallvacuum pump. This method, though successful inthe hands of the originators, Hulen and Barraquer,had not proved so successful in the hands of others.The suction of the best of vacuum pumps was unsteady,and the risk of the loss of vitreous was greater. Yetanother method, that employed by Mr. Sinclair himself,was performed with the aid of blunt capsule forceps,for the purpose of grasping the capsule and with-drawing the lens. This method was used by Kalt, ofParis, in 1910, who designed the forceps known byhis name. This method was studied by Stanculeanu,who performed a narrow iridectomy ; he also examinedthe capsule before operation with a view to judgingits toughness and its capability of standing the strainof traction. Knapp of New York, who had used themethod since 1911, employing Kalt’s forceps, had pub-lished a summary stating that in ten years’ experiencehe had not found late deterioration or change whichmight be ascribed to the method of operation ; further,there had been no vitreous changes, updrawn pupil,or iris prolapse.
Mr. Sinclair proceeded to describe his own technique.The lens was first carefully examined and the type ofcataract determined as far as possible. At the opera-
tion, after a large incision, iridectomy was first per-formed followed by insertion of forceps, first openingand then closing with slight pressure against the lens ;i this way a fold of capsule could be firmly grasped.Gentle forward traction was first employed, then,after a pause, traction was made in different directionsupwards ; this caused the suspensory ligaments belowto give way one at a time ; this step took about30 seconds. After this the lens became pear-shapedand could be delivered with comparative ease, com-plete in its capsule. The forceps employed were amodification of Kalt’s ; they were large-bladed andtoothless, slightly curved and provided with a
hollow into which the capsule tissue was bunched,thus rendering the grip more efficient.
Regarding results on all cases (52 ), 16 obtained6/6 vision ; 18, 6/9 ; 6, 6/12 ; 7, 6/18 ; 2, 6/24 ; 2, 6/36,one case with 6/36 vision had retinal haemorrhage atthe macula and one case lost the sight of the eye fromsevere infection. Vitreous loss occurred in seven cases ;vision in these was 2, 6/9 ; 2, 6/18 ; 2, 6/24 ; ], 6/36 ;improvement in vision took place later. In 18 cases thecapsule ruptured, leaving remnants in the eye as in thecapsulotomy method. In three cases the forceps failedto grasp the capsule over a swollen lens and capsulec-tomy was performed. Concluding, Mr. Sinclairremarked that this was the least traumatic of theintracapsular methods, and the apparatus was ofthe simplest. The paper was illustrated by numerouslantern slides and was concluded with a kinemato-graph demonstration of the whole operation.
Discussion.
Dr.W. G. SYM said he preferred the usual capsulotomymethod, though undoubtedly the intracapsular methodavoided the possibility of having to needle remnantsafterwards; on the other hand, with the capsulotomymethod, the anterior capsule could be removed and noiridectomy had to be performed.-Dr. J. V. PATERSONpointed out that this intracapsular operation was theideal one, but was attended with such grave dangerthat continental papers said that it was appalling andought not to be allowed. In the hands of a highlyskilled surgeon the operation was eminently successful,but the risk was too great to be undertaken unless bythe most highly skilled.-Dr. E. H. CAMERON alsospoke.
Dr. CRANSTON Low gave a communication on
Immunity and S’ensitisatiofz in Ringworm and Far.2cs.He stated that, although ringworm was verycommon in this country, little attention had beenpaid to changes in the body as a result of infection.He proceeded to review the work on the subjectwhich had been done, especially in Germany and Italy,during the last 20 years, and to give some personalexperiences. Favus and ringworn, he said, were
apparently local conditions, and when treated byiodine or other antiseptics the lesion disappeared.But farm-workers, having been once infected bycattle ringworm, were afterwards immune. Neisserand Plato experimented on these lines and attempteda treatment by means of a sterile filtrate of a crushedculture of the fungus prepared in the same way as" Old Tuberculin"; this they called "trichophytin."It was found that when this was injected into personssuffering from deep-seated ringworm marked local,systemic, and focal reactions followed, which, however,did not occur in persons not suffering from ringwormor in those in whom the condition was superficial.This showed that some tissue changes had occurred insufferers frcm the condition when deep seated-inother words, they had become sensitised to theinfecting agent. Experimentation was carried out onthese lines afterwards by several workers on animalsand man, and it was definitely shown that after inocula-tion with ringworm or favus the subject became lessprone to later inoculation and eventually developedan immunity. Regarding serum, it was found thatin marked cases of deep-seated ringwoJm a positivefixation reaction was obtained with a trichophytinantigen. Dr. Low experimented to see whether a
