534 fir:,t. The ring knife for curetting the ethmoidal cells should be introduced with the blunt edge towards ’the septum and the cutting edge should be turned not upwards but towards the orbit. It should be passed without force ’directly upwards and backwards, then drawn horizontally forward. After the operation the upper portion of the nose became lined with a white starred membrane. A continu- ance of the suppuration after curetting might mean suppura- tive, disease in the other sinuses, the sphenoidal or the frontal. As to the dangers of the operation, his own statistics showed 1 death in 300 cases. As to the results of the operation at the hands of others he had learnt that 11 operators had had no deaths and three had had six deaths, .all due to meningitis. The operation was serious, but he thought that the risks were justified. Little danger attended the operation if performed skilfully and with aseptic precautions. The patient should be under 40 and ,Iiot over 50; after the latter age the bones in the ethmoidal region were more brittle. A rise of tempera- ture after operation was not uncommonly due to pack- ing the nose ; if hæmorrhage occurred the nose had to be packed. The administration of vaccine preparatory to the operation was considered to obviate fever. Amongst the complications the orbital bone might be fractured and sub- sequently evidenced by a black eye. He regarded the opera- tion with the curette as the best method of dealing with cases of uncomplicated ethmoidal suppuration. Dr. W. L. BALLENGER (Chicago), continuing the intro- duction of the subject, said the disease might be acute or chronic, and that obstructive lesions in the nose were asso- ciated with the disease. When chronic, the nasal obstruction was a factor, and in acute cases the predisposing cause was not uncommonly a lowered vitality, which might be induced bv nasal obstruction. He described his method for the com- plete exenteration of the ethmoidal labyrinth. He had found that violent reactions and high temperatures followed partial operations. He exhibited the instruments used for .the removal of the entire ethmoidal mass. Cases in which the ethmoidal cells extended over the orbit called for an ,external operation. He never packed the nose, and he had had but one death out of a large number of cases. Dr. H. P. MoSHER (Boston). continuing the discussion, said that formerly he had found intranasal operations in the sphenoidal region unsatisfactory and had preferred the . external method. Since he had become acquainted with the work of Dr. Ballenger he had returned to the intranasal method. He briefly summarised the results of his anatomical . investigations. Dr. P. WATSON-WlLLlAMS (Bristol) considered that an antero-posterior as well as a posterior obstruction of the nose was a source of great danger even if an ethmoiditis had not been established. He regarded the disease as an infective process of an insidious nature. The object of the operative treatment should be to establish sufficient drainage, and for ’ that purpose he preferred the forceps before the curette. Dr, WILLIAM HILL (London) dealt with the extent of the ethmoidal region, which lie thought had been exaggerated. Mr. R. H. WOODS (Dublin) was opposed to vaccine treatment. Mr. HERBERT TILLEY (London) was a supporter of Dr. Lack’s method of operating, as more direct and quicker. The average English patient required the treatment if possible to be carried out at one sitting and under chloroform. He used the ethmoidal forceps. - Mr. F’. H. WESTMACOTT (Manchester) was against external operations. He preferred general anaesthesia for the primary operation and local anæsthesia for subsequent surgical treat- ment. He inquired of Professor Hajek his method of correcting a deviated septum when present in cases of sup- purative ethmoiditis, whether by a submucous resection or by fracture of the deviated part. He also inquired why it was that after the removal of nasal obstruction at times the olfactory sense, previously lost, returned while at other times it did not. Dr. W. JOBSON HORNE (London) said that whilst the title of the discussion was useful to themselves in defining its cope, nevertheless it might be misleading to others, inas- much as it might create the impression that chronic sup- purative ethmoiditis was an entity. It was quite evident from what had been said that the sphenoidal and frontal sinuses were not uncommonly involved. Moreover, both on anatomical and developmental as well as on clinical grounds, it was as well to regard the sphenoidal and frontal sinuses as more highly developed cells of the ethmoidal labyrinth. He lirged the use of X rays’in the investigation of the extent of the disease and of the presence or absence, as well as the size and situation, of the larger cells. He was opposed to operations which necessitated blindly groping in the dark. The operative treatment, he considered, should be done under direct ocular inspection. Dr. A. BRONNER (Bradford) objected to general anesthetics in operations upon the ethmoid. It was necessary to remove any intranasal obstruction. He did not regard Dr. Lack’s operation as the operation of the future. Professor HAJEK, in replying, again urged the importance of a perfect diagnosis and of everything operative being done under the eye. The anatomy varied so much that it was impossible to generalise. The middle turbinate body had to be removed in most cases to see what to do. If there were no subjective symptoms, and little or no pus, there was no reason for operating. Dr. LAMBERT LACK, in his reply, expressed his satisfaction with the debate and his gratification at learning that so many had practised his operation. He regarded his opera- tion, not as the one of the future, but as the one of to-day. Dr. BALLENGER also replied. PATHOLOGY. FRIDAY, JULY 26TH. President, Professor I. WALKER HALL (Bristol). Dr. T. J. HORDER (London) read a paper on The Investigation of Puncture Fluids as an Aid to Dzaptosis and Treatment. In this he touched first on the technique which, simple though it appeared, was often barbarous in its application from the attempt to use blunt or rusty needles, &c. He grouped the various punctures into punctures of certain cavities, of certain solid organs, and of certain adventitious structures (e.g., abscesses, cysts, &c.). He considered that in skilled hands there were no dangers or ill-effects from the procedure, but he was not prepared to carry out pleural or lumbar puncture in the out-patient department or consulting room. The patient should be kept in bed for 24 hours afterwards. Even lung punctures he regarded as safe. He would submit the fluid so obtained to cytological, chemical, physical, and bacteriological investigation, though one or other was usually of special importance according to the case in question. He summed up the value in diagnosis by saying that cytological examination, broadly speaking, diagnosed between tuberculous and pyogenic inflammations. Chemical examination of fluids from serous sacs determined whether they were transudates or exudates. Parasyphilitic disease often gave a cerebro-spinal fluid containing a globulin; urasmia a fluid with urea. Bacteriologically the causal agent in meningitis, arthritis, pleural effusion, pneumonia, &c., was recognised and often allowed of a very early diagnosis before definite clinical signs appeared. The puncture like- wise was often of therapeutic value-e.g., drainage of pleural effusion, meningitic effusion, joints, &c., apart from the fact that the earlier the diagnosis be made the more sure the results of treatment. Dr. PURVES STEWART (London) agreed that pyogenic infections usually produced a polymorph leucocytosis, whereas tuberculous infection usually produced a monomorph leucocytosis, but this rule was not absolute, for during con- valescence from a pyogenic infection of the meninges the cerebro-spinal fluid passed through a later stage of monomorph leucocytosis on the way to recovery. Further, during an acute attack of tuberculous meningitis the leuco- cytosis was not infrequently of a polymorph type. He believed that not the particular organism determined the type of the leucocytosis, but the acuteness of the infection-- an acute infection producing the polymorph, a subacute or chronic one the monomorph leucocytosis. Moreover, even an infection was not essential for the production of leuco- cytosis. He had experimentally injected the spinal theca in monkeys with a sterile emulsion of carmine when studying the lymph-paths within the spinal cord. In every case there was produced a temporary polymorph leucocytosis, changing within a few days to a monomorph leucocytosis, and ultimately clearing up entirely. He had never found a general anaesthetic necessary to perform thecal puncture. ’
Transcript
534
fir:,t. The ring knife for curetting the ethmoidal cellsshould be introduced with the blunt edge towards ’the
septum and the cutting edge should be turned not upwardsbut towards the orbit. It should be passed without force’directly upwards and backwards, then drawn horizontallyforward. After the operation the upper portion of the nosebecame lined with a white starred membrane. A continu-ance of the suppuration after curetting might mean suppura-tive, disease in the other sinuses, the sphenoidal or thefrontal. As to the dangers of the operation, his ownstatistics showed 1 death in 300 cases. As to the results ofthe operation at the hands of others he had learnt that 11
operators had had no deaths and three had had six deaths,.all due to meningitis. The operation was serious, but he
thought that the risks were justified. Little dangerattended the operation if performed skilfully and with
aseptic precautions. The patient should be under 40 and,Iiot over 50; after the latter age the bones in theethmoidal region were more brittle. A rise of tempera-ture after operation was not uncommonly due to pack-ing the nose ; if hæmorrhage occurred the nose had to bepacked. The administration of vaccine preparatory to theoperation was considered to obviate fever. Amongst thecomplications the orbital bone might be fractured and sub-sequently evidenced by a black eye. He regarded the opera-tion with the curette as the best method of dealing with casesof uncomplicated ethmoidal suppuration.
Dr. W. L. BALLENGER (Chicago), continuing the intro-duction of the subject, said the disease might be acute orchronic, and that obstructive lesions in the nose were asso-ciated with the disease. When chronic, the nasal obstructionwas a factor, and in acute cases the predisposing cause wasnot uncommonly a lowered vitality, which might be inducedbv nasal obstruction. He described his method for the com-
plete exenteration of the ethmoidal labyrinth. He had foundthat violent reactions and high temperatures followed
partial operations. He exhibited the instruments used for.the removal of the entire ethmoidal mass. Cases in whichthe ethmoidal cells extended over the orbit called for an,external operation. He never packed the nose, and he hadhad but one death out of a large number of cases.
Dr. H. P. MoSHER (Boston). continuing the discussion,said that formerly he had found intranasal operations in thesphenoidal region unsatisfactory and had preferred the. external method. Since he had become acquainted with thework of Dr. Ballenger he had returned to the intranasalmethod. He briefly summarised the results of his anatomical
. investigations.Dr. P. WATSON-WlLLlAMS (Bristol) considered that an
antero-posterior as well as a posterior obstruction of the nosewas a source of great danger even if an ethmoiditis had notbeen established. He regarded the disease as an infectiveprocess of an insidious nature. The object of the operativetreatment should be to establish sufficient drainage, and for’ that purpose he preferred the forceps before the curette.
Dr, WILLIAM HILL (London) dealt with the extent of theethmoidal region, which lie thought had been exaggerated.
Mr. R. H. WOODS (Dublin) was opposed to vaccinetreatment.
Mr. HERBERT TILLEY (London) was a supporter of Dr.Lack’s method of operating, as more direct and quicker.The average English patient required the treatment if
possible to be carried out at one sitting and under chloroform.He used the ethmoidal forceps.
- Mr. F’. H. WESTMACOTT (Manchester) was against externaloperations. He preferred general anaesthesia for the primaryoperation and local anæsthesia for subsequent surgical treat-ment. He inquired of Professor Hajek his method of
correcting a deviated septum when present in cases of sup-purative ethmoiditis, whether by a submucous resection orby fracture of the deviated part. He also inquired why itwas that after the removal of nasal obstruction at times theolfactory sense, previously lost, returned while at other timesit did not.
Dr. W. JOBSON HORNE (London) said that whilst the titleof the discussion was useful to themselves in defining itscope, nevertheless it might be misleading to others, inas-much as it might create the impression that chronic sup-purative ethmoiditis was an entity. It was quite evidentfrom what had been said that the sphenoidal and frontalsinuses were not uncommonly involved. Moreover, both onanatomical and developmental as well as on clinical grounds,
it was as well to regard the sphenoidal and frontal sinusesas more highly developed cells of the ethmoidal labyrinth.He lirged the use of X rays’in the investigation of the extentof the disease and of the presence or absence, as well as thesize and situation, of the larger cells. He was opposed tooperations which necessitated blindly groping in the dark.The operative treatment, he considered, should be doneunder direct ocular inspection.
Dr. A. BRONNER (Bradford) objected to general anestheticsin operations upon the ethmoid. It was necessary toremove any intranasal obstruction. He did not regard Dr.Lack’s operation as the operation of the future.
Professor HAJEK, in replying, again urged the importanceof a perfect diagnosis and of everything operative being doneunder the eye. The anatomy varied so much that it was
impossible to generalise. The middle turbinate body had tobe removed in most cases to see what to do. If there wereno subjective symptoms, and little or no pus, there was noreason for operating.Dr. LAMBERT LACK, in his reply, expressed his satisfaction
with the debate and his gratification at learning that so
many had practised his operation. He regarded his opera-tion, not as the one of the future, but as the one of to-day.
Dr. BALLENGER also replied.
PATHOLOGY.
FRIDAY, JULY 26TH.President, Professor I. WALKER HALL (Bristol).
Dr. T. J. HORDER (London) read a paper onThe Investigation of Puncture Fluids as an Aid to Dzaptosis
and Treatment.In this he touched first on the technique which, simplethough it appeared, was often barbarous in its applicationfrom the attempt to use blunt or rusty needles, &c. He
grouped the various punctures into punctures of certain
cavities, of certain solid organs, and of certain adventitiousstructures (e.g., abscesses, cysts, &c.). He considered thatin skilled hands there were no dangers or ill-effects from theprocedure, but he was not prepared to carry out pleural orlumbar puncture in the out-patient department or consultingroom. The patient should be kept in bed for 24 hoursafterwards. Even lung punctures he regarded as safe. Hewould submit the fluid so obtained to cytological, chemical,physical, and bacteriological investigation, though one or
other was usually of special importance according to the casein question. He summed up the value in diagnosis by sayingthat cytological examination, broadly speaking, diagnosedbetween tuberculous and pyogenic inflammations. Chemicalexamination of fluids from serous sacs determined whether
they were transudates or exudates. Parasyphilitic diseaseoften gave a cerebro-spinal fluid containing a globulin;urasmia a fluid with urea. Bacteriologically the causal agentin meningitis, arthritis, pleural effusion, pneumonia, &c.,was recognised and often allowed of a very early diagnosisbefore definite clinical signs appeared. The puncture like-wise was often of therapeutic value-e.g., drainage of pleuraleffusion, meningitic effusion, joints, &c., apart from the factthat the earlier the diagnosis be made the more sure theresults of treatment.
Dr. PURVES STEWART (London) agreed that pyogenicinfections usually produced a polymorph leucocytosis,whereas tuberculous infection usually produced a monomorphleucocytosis, but this rule was not absolute, for during con-valescence from a pyogenic infection of the meninges thecerebro-spinal fluid passed through a later stage ofmonomorph leucocytosis on the way to recovery. Further,during an acute attack of tuberculous meningitis the leuco-cytosis was not infrequently of a polymorph type. Hebelieved that not the particular organism determined thetype of the leucocytosis, but the acuteness of the infection--an acute infection producing the polymorph, a subacute orchronic one the monomorph leucocytosis. Moreover, even
an infection was not essential for the production of leuco-cytosis. He had experimentally injected the spinal theca inmonkeys with a sterile emulsion of carmine when studyingthe lymph-paths within the spinal cord. In every case therewas produced a temporary polymorph leucocytosis, changingwithin a few days to a monomorph leucocytosis, and
ultimately clearing up entirely. He had never found ageneral anaesthetic necessary to perform thecal puncture. ’
535
He described a method whereby one could perform thecalpuncture even on a violent patient by fixing his knees to hischin with a roller-towel or a strong portmanteau-strap.
Dr. J. M. BERNSTEIN (London) commented on the findingof a marked lymphocytosis in some cases of acute
needles in a solution of 1 part lysol and 12 parts dehydratedspirit, which prevented the formation of rust. He agreedwith Dr. Stewart as to the occasional finding of a poly-morphic tuberculous cerebro-spinal fluid, and asked fordetails as to the preparation and fixation of films from thecerebro-spinal fluid.
-.. - -
Dr. HORDER, in replying, agreed with Dr. Stewart as tothe occasional polymorphonuclear increase in tuberculousmeningitis, but these cases were usually acute, whereas incontrast he had occasionally found a lymphocytic increasein meningococcal exudates of chronic standing. So that heconsidered the nature of the cell exudate was dependent onthe rate of its formation rather than upon the nature of theinfection. The’formula must be taken as a general rule
only. It was not invariable. In a recent report to theLocal Government Board Dr. Gordon showed that a moderate
lymphocytosis existed in acute poliomyelitis, but that if acareiul consideration were given to all the tests-chemicaland cytological-applied to the flnid there was no difficultyin differentiating the various conditions.
Dr. C. BOLTON (London) then read a paper onThe Rôle of the Gastric Juice in the Pathology of Gastric
Ulcer.He said that the pathological processes present in gastriculcer involved so many factors that it was impossible to obtainfrom the study of human pathology alone an exact idea ofthe influence exerted by the gastric juice. One must, there-fore, resort to the experimental method. In this series of
experiments the ulcers were produced in the first instance bythe injection into animals, either locally or viii the peri-toneum, of a gastro-toxic serum prepared by the author’sprocess of immunisation, the animals used being the guinea-pig and the cat. It was found that when the gastric juicewas put out of action by neutralisation with an alkaliulceration failed to appear. The actual necrosis was,therefore, brought about by the gastric juice, and no
microscopic change could be found in the cells precedingtheir digestion by the gastric juice. The change inthe cells which brought about self-digestion was not dueto the removal of the influence of any specific anti-
body, because other blood poisons reacted in a similarmanner. This established the principle that variousblood poisons might bring about self-digestion without
actually causing necrosis of the gastric mucous membrane.It was found that the gastrotoxic lesions were increased byhyperacidity of the gastric juice, the HCl acting as a proto-plasmic poison. Other substances acted in like manner ; forinstance, acetic acid of one-eighth the strength of vinegar,caused a marked increase of the ulceration. The rapidityof formation of an ulcer was found to vary in proportion tothe activity of the gastric juice, and to depend largely onthe kind of diet administered. With regard to the healingof the ulcers, it was demonstrated that so long as the motorpower of the stomach remained normal any increase or
ctiminution in tne acidity 01 tne gastric juice to tne extentfound in human pathology had no tendency to impede thehealing process. When pyloric stenosis, leading to retentionof food, was produced, the healing was definitely delayed forat least twice the normal time. The delay occurred in theearly stages, and was due, not to a fault in the epithelium,but to necrosis of the connective tissue base of the ulcer andalso to excessive formation of fibrous tissue in it, the youngcells having no cellular stroma over which to giow. This wasdue to the prolonged action of the gastric juice on theconnective tissue. For the same reason it was found thatin normal animals the ulcers healed most rapidly when theanimals were fed on food which left the stomach quietlyand excited only a moderate flow of gastric juice. In thetreatment of a case of gastric ulcer, therefore, the acidityof the stomach contents should be kept low by the adminis-tration of alkalies. The diet should be free from irritants,and should consist of food-stuffs which remained only ashort time in the stomach and excited only a moderate flowof gastric juice. If dilatation of the stomach and retentionof food owing to muscular insufficiency, which resisted
medical treatment, or pyloric stenosis, were present, gastro-
enterostomy should be performed.Sir BERTRAND DAWSON (London) pointed out that thepaper just read was of even greater importance than theprevious papers of Dr. Bolton, as it threw some light onthe formation of chronic ulcer, which was the reallyimportant point in human beings that demanded explana-tion. Clinical experience bore out the view that the stageof acute or mucous ulcer often showed evidence of microbic-or toxic invasion of the stomach, whereas in chronic ulcerthe chief factor at work was the hydrochloric acid. In theformer there was often a normal or lowered HCl content,whereas in the latter hyperchlorhydria was present. It wasan important observation that other acids favoured ulcerformation. He suggested that the reason why the cats thatwere fed on meat healed more slowly than those fed onmilk was that meat diets remained longer in the stomach.He had found that middle-aged people with gastric ulceroften showed evidence of delayed stomach emptyingindependently of pyloric obstruction.
Dr. BoLTON, in replying, reminded Sir Bertrand Dawsonthat when chronic gastric ulcer existed an acute injectionelsewhere, such as in the finger, often led to an acute spread.of the gastric lesion.
Dr. SHENNAN and Dr. J. H. HARVEY PIRIE (Edinburgh)discussed the
Etiology of Dissecting Aneurysms.They pointed out that the commonly accepted explanation ofthe causation of dissecting aneurysm did not apply in all
cases. Many of these occurred in the absence of nodularatheroma or atheromatous ulceration of the intima of theaorta. In recent cases which they had examined they hadfound important degenerative changes in the media affecting-the elastic tissue, as well as the connective tissue and theunstriped muscle fibres, and affecting especially the middlethird of the media. In the intima the elastic tissuehad largely disappeared, and its structure had become
opened up, in addition to underlying moderate fattydegeneration, so that it readily gave way when the
support of the media was lost. They applied to the humanaorta the results obtained by engineers, from examination oftubes exposed to great internal strain, but a more importantconsideration was that the area of the wall especially affected:was that farthest removed from its supply of nutrition,whether from the vasa vasorum or from the lumen of thevessel. Other authors explained the rupture of the wall on.the ground of (1) increased blood pressure, (2) actual trauma_or (3) degeneration of the wall. The present authors from.their work concluded that the last factor was the most
important, the others being capable of exclusion in some ofthe cases encountered by themselves or reported by others.The paper was illustrated with the lantern.
Dr. H. MACLEAN (London), in a paper on
, Testing Urines for Sugar,
remarked that in this country the two tests employed intesting urine for sugar were Trommer’s test and Fehling’stest. Trommer’s test was exceedingly simple, as only two-reagents were required-CuS04 and NaOH-but it demandedgreat care in its application. If, for instance, a urine ofspecific gravity 1016-1018 was examined for sugar by-Trommer’s test the result depended very greatly on the orderin which the reagents were added. If the copper sulphatesolution was first added to the urine and then the sodium,
hydrate, it would be found that a considerable amount ofthe cuprous hydroxide formed passed into solution and a
deep blue fluid was obtained, which on heating might give areduction. Both the formation of the blue liquid and thereduction on heating strongly suggested sugar but on treatinga sample of the same urine, first with sodium hydrate, andthen with copper sulphate, much of the cuprous hydroxide-formed remained undissolved and on heating no reductionoccurred. When tested by other methods this urine wasfound to contain only the physiological trace of sugar-present in normal urine. Salkowski and Schulz ascribedthis anomalous result to the presence of creatinin. On theother hand, when the alkali was added first, the subsequentaddition of too much copper might result in a reaction being-obtained with a normal urine. Thus in the presence of smallamounts of sugar the interpretation of Trommer’s test was.not always easy. In the case of Fehling’s test manydifficulties were also encountered, but it had been found that
536
urines giving more or less ill-defined reactions with this testdid contain sugar somewhat in excess of the normalamount per cubic centimetre of urine. This might be dueto concentration, but often there was an absolute increase.These anomalous reactions depended on the interferingpower of creatinin, which possessed the power of holdingreduced cuprous oxide in solution. For this reason a urine
containing sufficient sugar to react with Fehling’s solutiongave no reaction when tested in the ordinary way. Here the
sugar reduced its equivalent amount of cupric oxide to thecuprous form, but no precipitate was formed because thereduced oxide remained in solution. Creatinin also
possessed the power of modifying the nature of the pre-.cipitate formed. If a urine contained slightly more sugar thannormal and a reaction took place on boiling with Feliling’ssolution, the precipitate might separate in such a finely dividedform as to give a greenish or greenish-yellow opalescentfluid. With a little more sugar the particles of the reducedoxide were larger, and a yellow-coloured precipitate wasobtained. With excess of sugar the ordinary red granularprecipitate was in evidence. All these anomalous reactions
depended on the action of the creatinin present in the urineand were generally caused by sugar. The reducing power ofurine after the exhibition of such substances as alcohol andchloroform was often due to the presence of sugar. Manypatients were so susceptible to alcohol that a comparativelysmall amount produced marked glycosuria.
Sir BERTRAND DAWSON advocated the administration indoubtful cases of slight glycosuria of a test meal of 100grammes of glucose. He had also found that temperatehabits in young people would remove mild degrees of
glycosuria. He sought for information as to the significance.of temporary glycosuria.
Dr. P. J. CAMMIDGE (London) thought that on account ofthe many fallacies in connexion with Trommer’s test and
Fehling’s test great care should be taken in interpreting theresults. Latterly he had been using Benedict’s test, whichhad the advantage of using a single solution that keptindefinitely and required only a very small quantity of urine.Slight reactions were to his mind of great importance, andunless a test meal of sugar showed that the cause was but a
temporary one, the suspicion should be aroused that the
patient was a potential diabetic, and the diet should beworked out on the basis of the experimentally determinedsugar tolerance.The PRESIDENT pointed out that in glucose test meals it
was important to exclude the action of protein as a greatirritant of the sugar-producing mechanism. He consideredthat it was advisable to diminish the intake of protein alittle below the average on the days when the glucose wasgiven.
Dr. MACLEAN, in replying, pointed out that he had notedthat experimentally animals could be made to produce aglycosuric condition when treated with alcohol.Dr. 0. T. WILLIAMS (Liverpool), in a paper on
The Exeretory Function of the Intestine in Relation toDisease,
pointed out that intestinal concretions, such as intestinal sand,fmcal concretions, enteroliths, and so forth, when investi-gated as to their chemical composition, structure, time, andsite of occurrence, were found to have many factors incommon, no matter in what part of the intestine or its
appendages they might have arisen. He considered them tobe manifestations of some abnormal condition in the excretionof the intestine and its appendages. In a previous note he hadshown a close similarity in the chemical composition of intes-tinal sand found in mucous colitis and of appendix concretions.He discussed in his present paper intestinal sand, appendixconcretions, intestinal concretions, and gall-stones. He
suggested that all were the result of excretion of themucosa of the intestine, and possibly consisted of thewaste products of fat metabolism, which in combinationwith calcium would form the concretions (which, indeed,-contained saturated fat or insoluble calcium soaps). These
soaps would easily cause obstruction in the appendix, or bydeposition on the mucosa and submucosa so diminish thevitality of the part as to allow of infection. In the widerbiliary passages there was room for the flow and eliminationof the soaps, but when the mucosa produced more easily pre-cipitable allied bodies concretions were formed. In the stillwider intestine there was ample room for elimination, and it
was only the effects that were produced-e.g"., mucouscolitis-but rarely even here concretions might be formed.He therefore propounded the view that all these states werenot due to local disorders, but were the manifestations of ageneral metabolic disorder which threw on the intestine orits appendages the onus of excreting deleterious products.
Dr. CAMMIDGE thought that the function of the intestinewas probably much more important than was generally sup-posed, and also that the heavy metals and fats were indeedexcreted. He had found that in colitis the saponified fatsand inorganic acids were nearly always increased.
Mr. D. P. DALBRECK WILKIE (Edinburgh) read a paper onThe Association of Duodenal Ulcer with Morbid Conditions in
the Ileum, Appendix, and Colon.He gave a description (illustrated by lantern slides) of 10cases of duodenal ulcer observed in the post-mortem room inall of which some pathological lesion was found in thelower reaches of the alimentary tract. In 3 of these casesdeath had resulted from acute appendicitis ; in 2 evidence ofold appendicular trouble was present, while in the remaining5 the appendix was healthy, but a more or less marked degreeof pericolitis, which by crippling the colon had led to fascalstasis, was present. In 2 cases, also, the lower end of theileum was bound down and the emptying of the smallintestine had evidently been interfered with. He believedthat the existence of these lesions in the lower bowel playedsome part in determining the chronicity of duodenal ulcer,and that at operation for duodenal ulcer they should belooked for and, where found, should be regarded as part ofthe condition producing the symptom-complex for which theoperation was undertaken.
PHYSIOLOGY.
FRIDAY, JULY 26TH,
President, Professor J. S. MACDONALD (Sheffield).Professor F. A. BAINBRIDGE (Newcastle) read a paper on
The Effects of the Retention of Urine.The question which he tried to answer was whether thedeath of animals after removal of large parts of the kidneyswas due to the absence of a normal internal secretion of the
kidneys or to a retention of urine. In his experiments hehad caused the retention of urine either by the division ofthe uterus or by the formation of an opening between thebladder and the peritoneal cavity; while a third manner wasthe collection of urine in the ordinary way and its re-injectioninto the animal. The animals all died in a state of comawithin 36-48 hours of the commencement of the experiment.The death occurred within the same time as in experimentsin which the kidneys were removed. Professor Bainbridgedrew the conclusion that death in the latter case was notdue to the removal of an essential internal secretion-for inhis own experiments such a secretion must have been
present. It was due to the retention of urine. Perhaps thedeath was caused by an upsetting of metabolism due toretention of acids.
Professor W. H. THOMPSON (Dublin) asked Professor
Bainbridge if he had repeated certain experiments ofBradford’s. He spoke of the toxic substances in urine andtheir nature.
Professor BAINBRIDGE, in reply, said that the alcoholicprecipitate and filtrate of urine were both toxic.
Dr. H. M. VERNON (Oxford) then read a paper on1’he Function of Lipoids in Vital Processes.
He stated that the narcotic action of chloroform, &c.,depended upon solution of the lipoids. He described ex-
periments upon the gaseous metabolism of the kidneys onperfusion with various alcohols ; and he showed some slidesillustrating his results. He came to the conclusion thatalcohol dissolved and destroyed some essential lipoid mem-brane. He then turned to the question of the reaction ofoxydase to alcohol. The reaction was a sharp one, andother narcotics--ether, chloroform, &c.-had a similardestructive action, destroying an essential lipoid membrane.
Professor MACALLUM (Toronto) drew attention to somework which seemed to show that the lipoids did not playthe role ascribed to them by some. Surface tension was amost important factor, and observations had been made toolargely from one point of view.
