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Medical Societies

ROYAL SOCIETY OF MEDICINE

Chronic Œdema of the LegTHE section of surgery met on April 5, with MR. DIGBY

CHAMBERLAIN, the president, in the chair, to discuss thetreatment of chronic oedema of the leg.

Prof. A. M. BOYD said that from analysis of 673cases a tentative classification had been adopted : (1)venous, (2) erythrocyanoid, (3) lymphoedematous, and(4) angiomatoid. Mixtures of several types were

frequently seen. Venous oedema might be complicatedby lymphoedema due to spread of inflammation throughthe vein walls to the perivenous lymphatic vessels ; or

erythrocyanosis frigida might be followed later by a" white leg," which in its turn might be complicatedby inflammatory oedema. The angiomatoid group wereusually seen in the pure state.

Describing the routine investigation of cases at

Manchester, Professor Boyd said that patients were

photographed, their limb-size was measured, and angio-graph and soft-tissue radiographs were taken. Venouspressures were measured by a modification of the methodused by Mr. A. J. Walker, of St. Bartholomew’s Hospital.There were two basic types of limb : (1) normal arterialcirculation (arteries and veins of normal calibre), and(2) erythrocyanoid type (both arteries and veins small-a half or a third of the normal calibre).The clinical manifestations of the various cedemas

depended on the type of limb involved : for example,a "white leg" would show less tendency to resolveif the limb already had a poor blood-supply. The same

applied to lymphœdema.Iliofemoral thrombosis-the typical " white leg "-

other than puerperal in origin, was commonly seen over40 years of age. Apparently spontaneous iliofemoralthrombosis over the age of 60 years was indicative of

malignant disease. Deep phlebitis in the calf veins wasusually traumatic in origin. Fungus infection was afrequent cause of otherwise unexplained phlebitis.

Certain cases of " lymphcedema of indefinite originwere probably venous in origin, due to progressive lossof valves in the deep veins. The contribution of thearterial, venous, and lymphatic factors must be assessedin the individual. Treatment of these oedemas consistedin ascertaining and remedying these factors.

Prof. IAN AIRD emphasised the importance, in thetreatment of chronic cedema, of appreciating individualdifferences. He suggested that solid non-pitting oedemawas the result of an original pitting oedema, but thatnot every case of chronic oedema developed into thenon-pitting kind. Why some should proceed to the

non-pitting state was not understood, but it was knownthat for solid oedema a high concentration of protein inthe oedema fluid was necessary, and this concentrationwas likely to be highest when there was completelymphatic obstruction. In the early stages of pittingcedema, conservative measures were probably sufficient.But consideration should be given at an early stage to thecause of the cedema, because some causes lent themselvesto additional specific therapy.

Reviewing the types of cases, Professor Aird pointedout that congenital cedema was becoming less frequent,which raised the question whether the diagnosis had beencorrect. In some cases chronic oedema was associated with

congenital auriculo-ventricular fistula. (Edema associatedwith bone injury usually improved within a year. Asuccession of attacks of cellulitis might proceed to chronic,non-pitting lymphoedema, which was not due to obstruc-tion of the lymph pathways so much as to the presenceof fixed local antibodies in the tissues ; in these cases

special treatment in the form of chemotherapy and

massage had some success. Quincke’s disease could alsobe treated by massage in the acute stage, and by sympa-thectomy ; but recovery often took place spontaneouslyafter a year. Lymphoodema præcox was the most

progressive and intractable of all.Professor Aird said in summary that the best hope

of controlling oedema of the leg was still the elasticbandage initially and the elastic stocking later ; thestocking should extend to the groin and be supportedby a suspender-belt. Solid oedema could be relievedonly operatively, by excision in two stages of the sub-cutaneous layer and the deep fascia. Amputation wasmuch less often necessary for elephantiasis of the legthan of the arm.

Sir ARCHIBALD MCINDOE said that chronic oedemahad always been, for the patient, one of the most dis-tressing and disabling conditions, and for the surgeonone of the most disappointing. In tropical climatesædema of the leg might be parasitic in origin ; or it

might be non-parasitic, due to lymphatic obstruction orother causes.

,

Listing the types of oedema. Sir Archibald doubtedwhether Milroy’s disease ever occurred outside thefamous family which Milroy described. Idiopathiclymphædema praecox, in adolescent females, was a,

non-inflammatory condition, probably due to a low-grade inflammatory process. Inflammatory lymph-oedema began as an inflammatory attack and spreadfrom the nodal points in the leg, the cause being a.

streptococcus or a staphylococcus. Secondary, lymph-oedemas formed a mixed group, covering all other typesof cedema. Sir Archibald explained that from his pointof view cases of idiopathic lymphoedema praecox and ofinflammatory oedema constituted the largest group. Withregard to lymphcedema, he felt that undue attentionwas being given to the venous as opposed to the

lymphatic aspect.Surgical intervention might take the form of reversing

the lymph-flow. This had very seldom caused lastingbenefit ; patients treated in this way needed verycareful postoperative elastic bandaging, which theycould have had without the operation. The centricobstruction might be traversed by providing a lymphaticbridge-from the leg to the axilla, for instance. Thiscould provide benefit, but it was a difficult and dangerousoperation which should only be done by a plasticsurgeon.

Sir Archibald described a series of cases in which thelymph-bearing area was removed. The subcutaneoustissue and deep fascia was removed down to the muscle.leaving large skin-flaps no deeper than a Wolfe graft.These dermo-epidermal flaps were then applied. Thewhole process was carried out at one or more operations.The results were most hopeful, although the operationwas only suitable in certain cases. The grafts mightact as a strong elastic bandage, or it might be that theremoval of the lymphatic tissue was itself curative.The oedema was still left at places where excision couldnot be done-the toes and the tendo achillis.

Lastly, oedema of the leg was a condition which, inthe early stages, should be medically curable, and helooked forward to the time when the inflammatoryprocesses could be brought under control.

Sir HAROLD GILLIES said that the operation of puttinga wick across a lymphatic block was the right one wherethere was a mechanical block, as in lymphoedema præcoxand traumatic cases.

Mr. A. J. WAr.AER, described the method of takingvenous pressures referred to by Professor Boyd. hithis an apparatus was adapted from a sphygmomano-meter, with a bottle of fluid and a length of ’ Polythene’tube, which was filled with the fluid and inserted into avein in the foot. The pressure was varied and the pointat which blood was seen to flow out into the tube was

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taken as the reading of the venous pressure. - Anadvantage of this apparatus was that readings could betaken during exercise. As to treatment, Mr. Walkerdescribed a series of 25 cases in which venous ligationwas performed. Of 21 patients who had been followedup for periods of three to twenty-one months, only 2were completely relieved of the oedema ; in 5 this wasabsent so long as they wore elastic bandages ; in othersthe improvement was less well-marked, and of all thesymptoms the cedema was the one which improved least.Mr. A. H. RATCLIFFE, D.PHIL., said that analyses had

been made of serum and tissue fluids, but from theresearch point of view the results were " depressinglynormal." The fluid in the limb might be described asafferent vascular, extravascular, and efferent vascular ;the relationship determined the existence and extentof the cedema. The total protein content of the extra-vascular fluid was usually about 0.5% ; rarely was itabove I %. The only positive finding which mightbe of interest was that the albumi -globulin ratio waseither high or the same as in the serum. The formerwas perhaps attributable to imbalance between theafferent vascular and extravascular fluids and the latterto impaired protein reabsorption.

Mr. S. S. RosE said that soft-tissue radiographsproduced a typical pattern depending upon the increaseof the fibrous fascial network. Early cases of

"

lymph-oedema" showed a fine " bubble " appearance, whichlater became a much thicker framework with a muchcoarser mesh. This change ran parallel to the pittingoedema and the resolution on elevation of the limb-the later cases showing only slight pitting on a solidbasis and being only slightly improved by elevation.(Edema of very recent origin—e.g., cardiac œdema—showed only ground-glass opacity. He also referred toa method of investigation of tissue-fluid circulation whichhe was using-namely, the subcutaneous injection of

radio-opaque water-soluble compounds and subsequentserial radiographs to measure the spread.Mr. PETER MARTIN said that patients treated by the

operation which Sir Archibald-Mclndoe had describeddid find that the distal parts of the foot swelled asbefore, but they were grateful because they lost therecurrent attacks of rigor and there was pronouncedgeneral improvement. Mr. Martin felt that the tissuehad to be excised because the damage was irreversible.

Mr. MICHAEL OLDFIELD said that he treated minor

degrees of oedema by using elastic bandages and raisingthe foot of the bed at night on high blocks. In grossoedema with elephantiasis, the results of Kondoleqn’soperation were unsatisfactory. He also believed thatif skin which was already damaged was used for skinflaps, cedema of the leg recurred. Excision of wideareas of skin-deep and subcutaneous fascia followedby free skin-grafting, produced a very thin leg whichwas ugly, but the patient could walk on it afterwards.

In his reply, Professor BOYD remarked that Mr.Walker’s method of venous-pressure determination wasuseful and interesting from the research point of view,but for practical purposes the rubber-bandage methodwas as good as any.

LIVERPOOL MEDICAL INSTITUTION AND

MANCHESTER MEDICAL SOCIETY

Tumours of Pancreas and ParathyroidAT a joint meeting on March 2, Prof. JOHN MORLEY

spoke on endocrine tumours of the pancreas and

parathyroid gland.Each of 6 patients from whom a single parathyroid

adenoma, had been successfully removed showed somedegree of generalised osteitis fibrosa, though none hadurinary calculi or calcification of the kidneys. No

fewer than 4 of the 6 patients had an osteoclastomaof the jaw ; and such a finding should always be followedby estimation of the serum calcium and phosphorus.In a 7th patient with the characteristic changes in theskeleton and the serum-calcium, no tumour was found,but there might have been one in the anteriormediastinum that escaped detection owing to failureto split the sternum. In the great majority of patientswith parathyroid adenoma a single tumour was present ;in not more than 6% of cases was there more than onetumour. The tumours occurred much more commonlyin the inferior than the superior parathyroids. - Whennot located in the normal position of the parathyroids,the tumours were most commonly found in the anteriormediastinum. They developed at any age ; and theywere commoner in females than in males in the propor-tion of 3 to 1. Generalised osteitis fibrosa cystica(often with spontaneous fractures) was the commonestclinical manifestation, but calculi were often found in theurinary tract. The diagnosis was confirmed by a

serum-calcium of over 12 mg. per 100 ml. and by aserum-phosphorus reduced below 3-5 mg. per 100 ml.

Professor Morley then described 4 patients from whomhe had, removed insulin adenomata of the pancreas.In 3 of these patients the tumour was single and small,situated in the tail of the pancreas ; in 1 there were fivetumours. All were benign. Of the 4 patients, 2 hadbeen diagnosed for some years as epileptic, and in 2cerebral tumour had been suspected ; 2 had on occasionbeen regarded as suffering from alcoholic intoxication.

In 88% of cases benign insulin adenomata were single,and in 12% multiple. The tumours were found in anypart of the pancreas and not predominantly in the tail.Less than 10% of all insulin tumours were malignant.The diagnosis rested on Whipple’s triad of symptoms :(1) nervous (or occasionally gastro-intestinal) attacksin the fasting state, (2) a fasting blood-sugar of 50 mg.per 100 ml. or less, and (3) immediate, or almostimmediate, relief by injection of glucose. The nervoussymptoms consisted of confusion, convulsions, coma, orcollapse, and occasionally there were periods of meaning-less laughter. These symptoms were apt to bring thepatients to neurological or psychiatric clinics, and itwas important that those in charge of these clinics shouldhave’ in mind the possibility of hypoglycaemic manifesta-tions of insulin tumours. The results of operativeremoval of these tumours were dramatic ; and almost

always cure was complete.

Reviews of Books

L’organisation des osP. LACROIX, professeur à la Faculte de Medecine deLouvain. Paris : Masson. 1949. Pp. 228. Fr. 900.

THOSE interested in problems of bone growth will beacquainted with the experimental studies of ProfessorLacroix which have been reported in a long series ofpapers during the last ten years. He has now gatheredhis results together in a small book, richly illustratedand abundantly annotated with references to the exten-sive literature of this subject. Of particular interestis the development of osseous tissue at the site of injectionof alcoholic extracts of growth-cartilage or of the implanta-tion of fragments of bone which have been killed byimmersion in alcohol. Probably, however, these experi-ments will need to be extended and amplified beforetheir significance can be finally assessed. There is onecurious omission in the discussion of the relation ofosteoclastic activity to the remodelling process at themetaphyses of growing bones-no reference is anywheremade to the important observations of E. Mellanby onthe influence of vitamin A on this process. The practicalapplication of Lacroix’s experimental work are every-where apparent; for this reason it needs to be carefullystudied by the orthopedic specialist.