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Regarding Table IV. as an ordinary frequency Idistribution, the following means have been obtained : I

It appears to be almost hopeless to arrive at aconclusion as to the true fatality rate from the fore-going calculations. All that can be written is thatthe rates obtained raise suspicions that the notifica-tion of puerperal fever is very incomplete, and thatin assigning deaths to puerperal sepsis the Registrar-General follows a rule differing from that adopted bythe profession in diagnosing the disease. It has longbeen recognised that a definition of " puerperalfever " is wanted for the purposes of notification.

Medical Societies.ROYAL SOCIETY OF MEDICINE.

SECTION OF LARYNGOLOGY: SUMMERMEETING.

THE summer meeting was held at the ManchesterRoyal Infirmary on June 15th and 16th, with Mr.C. A. PABKEB, the President, in the chair.The first part of the programme was devoted to

the reading and discussion of papers.Mr. DOUGLAS GUTHRIE (Edinburgh) read a paper on

Chronic Hyperplasia of the Upper Jaw.He said that this disease, although rare, might furnisha clue to the solution of some of the problems ofbone pathology. The microscopic appearance closely Iresembled otosclerosis, although the two diseasesperhaps differed widely in their pathogenesis. Mr.Guthrie described two cases, of a boy aged 5 and ofa girl aged 16, in both of whom the bony enlargementof the maxilla was unaccompanied by pain or othersymptoms. Lantern slides were shown to illustratethree specimens from the Museum of the RoyalCollege of Surgeons of England, including an upperjaw excised by Lord Lister. The relationship of thedisease to leontiasis ossea, to unilateral hypertrophy,and to other osseous tumours was also discussed andillustrated.Mr. T. B. LAYTON (London) said there were many

types of this disease, some of which were typicalexamples of leontiasis ossea. It was essential toseparate the types, but he considered that somemicrobic toxin was responsible and reminded thesection that a similar disease occurred in the anthro-poid ape and in the chimpanzee. ,

Mr. F. H. WESTMACOTT (Manchester), referring tohis work on this subject, pointed out that the bonyswelling involved the canine fossa and originatedfrom the alveolus. The bony changes were alwayslimited by the orbital plate, and a diminutive antrumof Highmore was present. He regarded the conditionas a reversion to an embryonic type, a reconstructionof the bone, and in no way associated with infection.

Mr. J. ARNOLD JONES (Manchester), from a seriesof 53 cases, offered some

Clinical Observations on the Lingual Tonsil.He divided the symptoms into three groups : (1)Vague aches, pains in the throat; (2) paroxysmalcough, and (3) dysphagia. The appearance of thelingual tonsil varied from a granular or varicosecondition to definite gross hypertrophy. Discussingtreatment, Mr. Jones referred to the dangers ofremoval of hypertrophies with the guillotine, andpreferred painting the tonsil two or three times aweek with a solution of 1 in 40 silver nitrate, or makinglinear ciuterisations with the electric cautery. As tothe results of treatment, out of 41 replies 11 reported

cures, 11 great improvement, 15 improvement, and4 no improvement.The PRESIDENT and several members took part in

the discussion, and it was generally considered thatin the majority of cases the importance of the lingualtonsil in the production of symptoms was over-

estimated.-Mr. JONES, however, maintained thatthe lingual tonsil was often overlooked, and that thetreatment which he had outlined, simple as it was,was worthy of a more extended trial.

Dr. D. R. PATERSON (Cardiff) discussed theTreatment of Large Foreign Bodies Impacted in the Gullet.He pointed out that in the majority of cases suchbodies were impacted in the cervical portion of thegullet. The difficulty of extraction per vias naturaleswas frequently enhanced by the septic nature of theforeign body, its jagged or pointed contour, and thelength of time it had been present in the gullet. Heinsisted on the importance of a careful and studiedsurvey of the case before adopting endo-cesophagealtreatment. Reference was made to the extremerapidity with which some foreign bodies inducedulceration of the oesophageal wall, the presence of afcetid odour or pyrexia being an indication for extremecaution during extraction. Any perforation, actualor suspected, of the cesophageal wall was an indica-tion for an external cesophagotomy. Dr. Patersoninvited opinions as to whether it was not soundertreatment to resort to the external operation in casesof difficult endo-oesophageal extractions or presence ofsepsis, without actual perforation of the gullet wall.

Sir WILLIAM MILLIGAN advocated the use of theexpanding oesophageal tube, and was of the opinionthat an external operation should be performed ifthe point of the foreign body was deeply embeddedin the cesophageal wall and difficult to extract.

Dr. WILLIAM HILL regarded foreign bodies withhooks or teeth impacted in the pharynx as an indica-tion for the external operation.

Mr. MUSGRAVE WOODMAN (Birmingham) com-

municated a further study of the varieties ofMalignant Disease of the ivasal Accessory Sinuses,

with lantern demonstrations of microphotographs.He pointed out the necessity for acquaintance withthe histology of the normal ethmoid, and consideredthat several sections of a tumour had to be made

before a definite opinion as to its nature could beevolved. In conclusion he illustrated, by lanterndemonstration, some further suggestions for thesurgical treatment of this condition.

Mr. F. H. DIGGLE (Manchester) read a paper onDiseases of the Thyroid Gland in their Relation to

Laryngology.He discussed the incidence of laryngeal and trachealcomplications in benign diseases of the thyroidgland, with special reference to vocal cord paralysisand tracheal compression. He stated that of 34cases examined during the last 18 months 7presented such complications. He considered, how-ever, that this proportion was probably too high.Of the 34 cases examined 20 were simple paren-chymatous goitres, 6 adeno-parenchymatous, 6exophthalmic, and 2 cystic goitres. He had onlyseen two cases of vocal cord paralysis in the casesexamined, one a functional adductor paresis in acase of exophthalmic goitre and the other a rightabductor paralysis due to haemorrhage into a cysticgoitre. After referring to the incidence of laryngealparalysis in retro-oesophageal or retro-sternal thyroidextensions, he pointed out that tracheal compressionor distortion was a more frequent complication.Radiographs were shown of two cases, aged 17 and15 years respectively, illustrating bilateral trachealcompression and the relief of such after partialthyroidectomy.

Mr. H. TILLEY referred to a recent case in whichan extension of the thyroid gland had insinuated itselfbetween the thyroid ala and the lateral laryngeal wall,producing a bulging inwards of one-half of the larynx.At noon on June 16th more papers were read.

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Mr. D. L. SEWELL (Manchester), in a paper on the

After-treatment of Empyema of the Maxillary Antrum(Denker’s Operation),

discussed the relative advantages of Denker’s opera-tion. He preferred to fashion a nasal flap, andto turn it on the floor of the sinus, packing itdown with a narrow strip of bismuth gauze. He leftthe buccal wound unsutured, and on the fourth dayremoved the gauze through the buccal opening.Concerning subsequent irrigation of the sinuses, Mr.Sewell was of the opinion that the best results were’obtained if no such treatment was adopted and onlysimple gentle nasal douching employed on and afterthe seventh day. For cases with persistent dischargein spite of such treatment he discussed the advantagesof irrigation with silver nitrate and colloidal silverpreparations. He was of the opinion that toozealous treatment by irrigation frequently spoilt anoperative result.

Mr. J. F. O’MALLEY traced the

Evolutionary Changes which the Nose Undergoes in theVertebrata.

Beginning with the lamprey and continuing throughfishes, amphibia, reptiles, birds, and mammals to man,he traced the stages of the evolution of the nose withits accessory sinuses as present in man. Runningparallel with the anatomical variations he demon-strated the physiological adaptations to origin, passingthrough the phases of a pure olfactory organ, thenwith powers related to assimilation and taste, andfinally to that of a respiratory organ at first subsidiaryto smell and then of equal importance.

Exhibitions of Cases and Demonstrations.The afternoon of June 15th was devoted to the

examination and discussion of several interestingclinical cases. The local members of the section,together with Mr. WOODMAN and Dr. DAVID THOMSON(Blackpool), had collected together a full and completevariety of cases which gave rise to instructive anduseful discussion.On the morning of June 16th Dr. P. WATSON-

WILLIAMS (Bristol) demonstrated his technique andmethod of exploration of the nasal accessory sinuses.

Dr. IRWIN MOORE (London) demonstrated hismethod for the reduction or destruction of thehypertrophied or diseased tonsil by means of causticsoda and slaked lime (London paste).An interesting demonstration of radiographs illus-

trating pharyngeal pouches, cardiospasm, and otherlesions associated with the specialty were shown byDr. Morrison and his colleagues in the new X raydepartment of the Royal Infirmary.

Dr. A. BURROWS showed cases treated by radium,and demonstrated his methods of application in malig-nant diseases of the nose, pharynx, and larynx.

’ The annual dinner of the section was held at theClarendon Club on June 15th, and the dinner, as

well as the other meetings of the section, were votedmost successful functions.

SECTION OF OPHTHALMOLOGY.A MEETING of this section was held on June Sth,

under the presidency of Mr. A. L. WHITEHEAD, when,a number of cases were shown.

Macular Change with Trerraor.Mr. H. M. JOSEPH showed a case of progressive

macular changes associated with tremor. Thepatient was a woman aged 34. Two and a half yearsago she had tremor of the right hand, but no visualdefect. When he saw her for the first time two yearsago there were light spots about both maculae, andthe corrected vision was 6/12. Since that date thespots had greatly increased in number. Vision hadnow fallen to 6/18, and the tremor was more markedand extensive. Wassermann was negative.

Mr. RAYNER D. BATTEN regarded the case as anadult instance of cerebro-macular disease. Probablythe same toxin might be at work, producing differentsymptoms at different age periods. Infantile, juvenile,

and senile types were now recognised, and the presentcase seemed to supply the missing link, the adulttype. He entered into the reasons he held thatview, and showed slides of various cases he knew of.- Mr. F. A. JuLER referred to a case under Mr. LesliePaton, a boy, aged 18, which Mr. Paton diagnosedas cerebro-macular degeneration, and said he (Mr.Paton) regarded it as a connecting link betweenamaurotic family idiocy and later cases of cerebro-macular degeneration.-Dr. GORDON HoLMES said hewas familiar with this tremor since the epidemics oflethargic encephalitis. He did not suggest that thispatient’s condition was a sequel to lethargic encephal-itis, but he thought the area of brain affected agreedin the two conditions. The most important patho-logical lesion in these cases was disease in the sub-stantia nigra and in the neighbourhood of themesencephalic nuclei ; it seemed to be a primarydegeneration of certain portions of the grey matterof the brain.-The PRESIDENT said that in the cases ofencephalitis lethargica he saw he had not noted anyfundus changes, a curious fact if the basal gangliawere affected.

Familial Nodular and Reticular Keratitis.Mr. MONTAGUE HINE read a paper on this subject,

based on three cases shown. This family, he said,helped to demonstrate a close connexion betweenthe two conditions which did not appear so obviouswhen seeing individual cases. Mr. Basil Graves,who examined these three cases with the cornealmicroscope, aptly described the appearance seen

in the two younger patients as a " fine sheenyspeckling," and suggested that the tissue might beimpregnated with a fine translucent granular deposit,which might have a refractive index different fromthat of the cornea. The girl, aged 10, gave a

history of slight headache, but no intolerance of light.Right vision was 6/12, left 6/9. In her the opacityconsisted of a number of fine lines, many of whichwere seen to be composed of tiny dots; but the lineshere did not form a meshwork, but remained separatedand uncrossed. One line suggested an obliteratedvessel, resulting from previous inflammation. In theleft cornea there was a combination of two of thelinear opacities with several of the small rings,similar to those in her brother. The mother, aged 36,said that her eyes had worried her since infancy ;she had not had them examined before Februarylast, when she came to be tested for glasses. Rightvision was 6/18, left 6/12. The central area of thecornea was seen to be studded with numerous, ratherclosely-set greyish-white opacities, some in the formof rings, others nodular, while in places the nodulesbecame confluent. The periphery of the cornea wasclear in each eye. The boy, aged 14, gave a historyof severe headaches and intolerance of light sinceinfancy. His corneae showed very similar changes tothose seen in his mother. There was one child whoseeyes were normal. In all the cases the Wassermannwas negative, but the maternal grandfather was saidto have had syphilis.

Mr. H. NEAME spoke of a case under Mr. J. H.Fisher’s care who had lines of opacity in one eye, andnodules in the other ; the lines appeared to be atabout the middle of the substantia propria.

Tuberculous Conjunctivitis.Mr. R. L. REA showed a young woman, aged 23,

with tuberculous conjunctivitis, in the form ofulcerative patches on the lids of both eyes. He hadarranged for her to be sent to Leysin, in Switzerland,to have the direct sunlight treatment, from which hehad seen there very good results. He hoped to showher again after she had received that treatment.

The Embryology of Congenital Crescents.Miss IDA C. MANN read a paper on some suggestions

on the embryology of congenital crescents, whichwas supplemented by some excellent micro-photo-graphs and drawings shown by the epidiascope. Themain thesis is as follows : The group of cases underconsideration are characterised by the fact that they

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are congenital, stationary, not necessarily associatedwith any one error of refraction, and situated, in70 per cent. of the cases, below the disc. There is,apparently, some factor which determines the greaterproportion of inferior crescents, which must be soughtin the normal development of the disc, since anabnormality is more likely to be associated with anormally existing embryonic structure than it is toarise de novo as a pure aberrance. The embryonicstructure in this case is the choroidal fissure. The

presence of congenital crescents in other situationsdoes not detract from the fact that the choroidalfissure is the determining factor in the inferior type.The presence of the fissure will merely account forthe preponderance of this type, since the essentialcondition for the formation of a crescent is that thepigmented outer layer of the optic cup should notreach quite up to the insertion of the optic stalk.The presence of the fissure merely allows of thisoccurring more easily below the disc than elsewhere.From the illustrations shown it can be seen that theessential difference from the normal consists of thefailure of the pigment epithelium and nuclear layersof the retina to reach the edge of the optic disc in itslower part ; hence there is a small area below thedisc in which all the elements of the retina exceptthe nerve fibre layer are absent, so that this layer isseparated from the sclerotic only by a very thinextension of the choroid. Developmentally it hasbeen shown that eversion of the unpigmented layerof the optic cup normally takes place in the upperend of the choroidal fissure. This is seen in a largenumber of vertebrates. In some animals, includingman, the small everted portion of the inner layerloses its connexion with the rest of the inner layerand disappears, but in some other types (birds) theconnexion is retained and nerve fibres grow into theeverted projection. If in man the everted portiondeveloped aberrantly and retained its connexionwith the inner layer, a condition resembling thatnormally present in birds might result. Such a

condition is present in a congenital inferior crescent,which bears a striking resemblance to the structure ofthe lower part of the disc of the normal bird. It maybe said that congenital crescents in any situation aredue to the failure of the pigment epithelium to reachthe site of implantation of the optic stalk. Thisfailure may occur anywhere, since aberrant differentia-tion of the various parts of the secondary opticvesicle is known to occur. It is, however, muchmore likely to occur below the disc than elsewhere,since it is normal here at one stage of developmentin man. Hence the greater frequency of inferiorcrescents, which can be looked on as developmentallyhomologous with the cauda of birds, the architecturalbasis of the cauda being present, though small, in thenormal human embryo. The failure of the choroid isdirectly correlated with the absence of the pigmentedepithelium, and the occasional failure of the sclera hasits parallel in the retardation of condensation alongthe fissure during development. I

The PRESIDENT complimented Miss Mann on her Jexposition and the beauty of her slides.-Sir WILLIAMLISTER argued that the inferior crescent was a retrac-tion crescent, similar to the ordinary retractioncrescent of myopia occurring on the macular side.-Sir JOHN PARSONS agreed with Miss Mann’s view. In

many cases the condition was associated with failurein closure of the choroidal fissure. With regard to themyopic so-called retraction crescent-a term he didnot like-he thought this was probably an atypicalcoloboma, and that it had no relation to the stretchingof the walls of the globe associated with myopia.

Miss MANN replied that the presence of staphylomabelow the disc could also be explained as part of theretardation of the sclerotic condensation along thelines of the fissure. She agreed that myopic crescents

Ialso had a congenital explanation, though in them Isome pathological process was superimposed.Mr. P. DOYNE read a brief paper on the Tournay

reaction, and it was discussed by Mr. J. H. FISHER Iand Mr. RAYNER BATTEN.

NORWICH MEDICO-CHIRURGICALSOCIETY.

A CLINICAL meeting of this Society was held at theNorfolk and Norwich Hospital on June 5th, withDr. ARTHUR CROOK, the President, in the chair.

Insulin in Diabetes.Dr. H. J. STARLING brought forward two cases of

diabetes to illustrate the benefits and limitations ofinsulin. Case 1 was a girl of 18 who was first admittedto hospital in October, 1919, with a long previoushistory of thirst and loss of weight. She had 32 gr.of sugar per oz. of urine with a total output in oneday of 2030 gr. Starvation for five days made theurine sugar-free. This case for three and a half yearshad been kept on a very low carbohydrate diet,which she only varied occasionally when temptationovertook her. She had steadily increased in weight,had always been of a healthy colour, and had managedto establish her menstrual periods lately. Case 2 wasa man, aged 30, admitted to hospital on April 16th,1921, with high sugar excretion and marked acetonuria.Was kept in 12 months. Starvation for varyingperiods of 2-5 days made the urine sugar-free, butafter 2-4 days of meat, eggs, and 10 oz. of 5 per cent.vegetables, sugar always reappeared, and his weightkept stationary. He was readmitted in June, 1922,in a condition bordering on coma ; acetonuria andsugar excretion very high. As starvation did notresult in abolition of sugar it was given up, and hewas put on a diet containing 51 g. of carbohydrateand of 1435 calories per day. His daily output ofsugar for the past six months averaged 784 gr.(46 g.) and he therefore retained a daily average of77 gr. (5 g.) of carbohydrate. Insulin-10 units-wasgiven on May 7th, and one slice of bread was givenin addition to his normal diet, but the sugar excretionwent up to 1560 gr. (93 g.). The daily amount ofinsulin was then increased, until for the past threedays he had been having 10 units at 6 A.M., 20 unitsat 12, and 10 units at 6 p.M.= 40 units a day. Forthe past 48 hours he had been sugar-free, except forthe specimens tested at 6 A.M. and 8 A.M. That doseof insulin was therefore about correct to enable himto retain the present intake of carbohydrate. The

blood-sugar before insulin was given was 0-56 per cent.,afterwards only reduced to 0’52.

Dr. Starling considered that insulin was of immensevalue in diabetic coma, in which condition 80--100 unitsshould be given with large doses of glucose, preferablyintravenously. He stressed the importance offrequent estimations of the blood-sugar. If that wasnot done there was only one other factor by which thedose of insulin might be graded. In order to preventan overdose being given it was necessary that a smallamount of sugar should always be present in theurine, which necessitated the blood-sugar remainingpermanently at a higher level than that which thepancreatic cells could deal with. That practice wasdiametrically opposed to Allen’s treatment, whichaimed at keeping the urine sugar-free, and thus givingthe cells of the islands of Langerhans a chance ofrecovering their proper function. When the sugarexcretion could be controlled by dieting, insulin wasnot required, but its use was essential in a class ofcases in which sugar was always present in the urine-in spite of the most careful dieting. The highest.percentage of blood-sugar occurred between 6 A.M..

and mid-day, and thus the larger doses of insulinshould be given in the morning. It was, however,dangerous to give the insulin over-night, as someonehad suggested, as with no meal to follow symptoms ofan over-dose might come on during sleep and be faradvanced before any signs of it were observed. At

present insulin therapy was in its infancy and thedrug should not be given indiscriminately, or byanyone not fully conversant with its effects.

Exhibition of Cases and Speeme7is.Mr. E. W. EvERETT showed four cases and

specimens, including a boy on whom he had operated