923ROYAL SOCIETY OF MEDICINE: UROLOGY.

of by some. Tarry cysts were found at operationin 77 per cent., and au adenomyoma in the recto-vaginal space in 63 per cent. A very important featurewas that the rectum was adherent in 76 per cent.,and there was need, the authors considered, for acareful investigation of the nature of the causalirritation.

The last contribution was a very elaborate one,supported by a wealth of photomicrographic slides,on the implantation of the human ovum, which wasgiven by Prof. J. H. TEACHER, of Glasgow. Heshowed that fertilisation and implantation did notcorrespond to any part of the cycle in particular,but might occur at various points. There was nota long delay in fertilisation, but spermatozoa had along viability. It seemed that rupture of the folliclenearly coincided with the insemination, and thatfertilisation took place very shortly after that.Fertilisation had occurred within four or five daysof the period being due, and as implantation didnot occur for at least seven days-some declared itwas ten days-it was not implantation of the ovumwhich stopped menstruation. That function wasstopped, in his view, by fertilisation.The thanks of the Congress were accorded Prof.

Teacher for his demonstration.

During the Congress an instructive pathologicalexhibition was held under the control of Dr. EverardWilliams. On Thursday members of the Congressdined together, and on Friday afternoon many opera-tions were witnessed at a number of London hospitals.

Resolution.

On Wednesday the Congress agreed unanimouslyto the principle of a resolution to go to the Ministryof Health. On Friday the exact terms were approved,also unanimously, as follows :-

" In the opinion of the British Congress of Obstetricsand Gynaecology, the most urgent requirement in connexionwith the problem of sepsis is the provision of adequateaccommodation for the reception and treatment of these

Icases in hospitals, supervised, wherever possible, by obstetricsurgeons."

ROYAL SOCIETY OF MEDICINE.

SECTION OF UROLOGY.

A MEETING of this Section was held on April 23rd,Mr. CYRIL NITCH, the President, being in the chair.A discussion on

Bacterial -Infectiot-3 of the Urinary Tractwas opened by Prof. LEONARD DUDGEON, who confinedhis remarks to a few of the types of infection thatmight be encountered. (1) A special group ofhaemolytic bacilli, isolated by himself, of which hehad met many hundreds of cases. The condition andthe bacillus strongly resembled that of paratyphoidat first sight. In a certain number of cases it hadbeen possible to recognise the same organism, byserological tests, in the intestinal tract of patientssuffering from urinary infection. The course of theinfection differed markedly from that due to B. coliin the short acute course lasting for two or three weeksand then clearing up completely. If relapses occurredthey were short. Patients suffering from this infectionwere more sensitive to vaccines than any others,and vaccine treatment produced immediate rise oftemperature and return of severe clinical manifesta-tions. Vaccine should never be given until thetemperature had been normal for several days, andmost cases recovered satisfactorily without it.(2) ) B. coli. Two strains of this bacillus were

encountered-a haemolytic variety, which accountedfor 70 per cent. of cases in the male and 30 per cent.in the female, and a non-haemolytic variety for whichthe sex percentages were exactly reversed. It was

easy to immunise rabbits with the former but verydifficult with the latter. The vast majority of colonbacilli were non-hsemolytic ; the other kind was metwith in certain cases of severe diarrhoea. It hadlong been believed that the intestinal canal was theorigin of B. coli infections of other parts, and he hadbeen able to prove this experimentally in a certainnumber of urinary cases. Treatment by vaccineswas not satisfactory ; it was very difficult to produceany degree of immune substances in the blood. An

autogenous vaccine should be used, because of thetwo types ; the haemolytic type was more likely tobe benefited by vaccines. If there was hyper-sensitivity to vaccine the dose should not be pushedor severe tissue damage might result. Animal experi-ments showed that if B. coli was held up in any partof the body it produced a suppurative lesion, as, forinstance, if injected into serous sacs. In chroniccases it had been proved that coli abscesses werepresent in the kidney in those instances where theadministration of vaccine caused rise of temperature.In those instances where he had investigated secondattacks he had found that the organism was alwaysidentical with that causing the first attack. Hetherefore concluded that it had lain dormant some-where in the urinary tract, although the urine mighthave cleared up completely. (3) B. proteus. Althoughsome people regarded this as a non-pathogenicorganism it might lead to the most acute infection,with the bacillus recoverable from the intestine andblood-stream. The urine in such cases was alkaline,containing a great deal of mucus, triple phosphates,and pus. A vaccine might be given when the acutestage was over and was sometimes successful.(4) Staphylococcus albus. The presence of this coccusin large numbers with pus in the urine was, in hisexperience, invariably associated with the existenceof a calculus.

Dr. E. LEPPER described experimental work onthe production of lesions in the kidney in rabbits byB. coli, in an attempt to account for the fact thatintravenous injection of the organisms rarely causedserious damage unless there was coincident obstructionto the flow of urine. Compression of the ureter for55 minutes resulted in necrosis of the cortex withmultiple small abscesses, distension of the tubules,and inflammatory reaction. Even so short a

compression as 15 minutes produced marked abscessformation, and if the animal were examinedimmediately, the pelvis was found to be distendedwith blood-stained urine and the renal vessels muchdilated. The effect of the obstruction appeared to beproduced by back pressure ; the urine, being secretedand unable to escape, caused such distension of theveins that rupture occurred with extravasation ofblood, containing bacteria, into the kidney substance.If no urine were secreted during the time of theexperiment none of these results occurred. Injectionof bacilli with no obstruction led to naked-eyelesions in 8 cases out of 50 only, with microscopicabscesses in 20 more. The process appeared to beone of bacterial embolism, setting up focal abscesseswhich might rupture into the tubules or on to thesurface of the papilla and occasionally might causeinfection of the whole pelvis. There was no knownreason why the vessels of the papilla were more liableto embolism than those of the cortex.

Sir JOHN TH03-ISON-WALKFR dealt with thediagnostic and therapeutic aspect of the problem,confining himself to those instances in which therehad been no previous disease of the kidney. Theacute case was ushered in by four or five days ofprodromal symptoms, insufficient to cause the patientto seek advice. These took the form of irritability,loss of appetite, hypersensitivity to heat and cold,a little frequency of micturition, a little more

flatulence or constipation or relaxation of the bowelsthan was usual. Then the attack began suddenlywith frequency of micturition, in all degrees of urgencyup to strangury. After a few hours there was rigorand rise of temperature. The urine was passed in

924

small quantities, was cloudy, offensive, and might Icontain a little blood. There was distension of thebowel and constipation. More localising symptomsfollowed, generalised abdominal pain finally settlingin the loin, sometimes taking the form of renal colic.A little rigidity and tenderness might be felt and alittle enlargement of the kidney. If the condition waspassing on to one of pyonephrosis there would be aswinging of the temperature, the local symptomswould be more severe, and the urine would becomeclear. But there might instead be difficulty in passingwater, going on to retention, or pain, a sense ofweight, and aching in the rectum with enlargementand tenderness of the prostate or distension of thevesiculae seminales. Or localising symptoms might beentirely absent. The attack might last 14 or 21 daysor drag on up to two or three months. Often therewere exacerbations or recurrence of symptoms aftercomplete subsidence. Uncommon symptoms were :(1) High temperature without other phenomenon.(2) Pain as the principal feature, either aching orsevere in nature ; such cases were liable to bediagnosed as appendicitis. (3) Renal colic, whichmight be just as acute with a descending ureteritisas with a descending stone. (4) Heematuria as thefirst symptom. In such a case the infective nature ofthe condition might be recognisable by the charac-teristic B. coli odour of the urine. (5) A sterile urineassociated with a suppurative cortical nephritis.There would be high temperature, but few local.symptoms, save an enlargement of the kidney dueto perinephritis which might pass on to perinephriticabscess. The cause was usually the staphylococcus,and a history of boils or other staphylococcal skininfection could usually be traced. Of the chronictypes Sir John Thomson-Walker considered three :(1) Recurrent pyelitis and cystitis. Of this varietythere were two types, the acute attack which sub-sided but was followed six months or a year later byanother and that by yet another. Between theattacks there were no symptoms save possibly alittle irritability of micturition and slight rise oftemperature. In the second type the infectionrecurred and the urine was sterile between the.attacks. Some of these must be genuine reinfections ;some were undoubtedly cases of infection of theseminal vesicles, but in the female it was difficultto see where the bacilli might lie dormant. (2) Chroniccystitis with quiescent pyelitis. These cases were

very difficult as the ureteric catheter alone wouldshow the real source of the trouble. The pyelitismight give rise to no symptoms at all. Out of100 cases of cystitis taken at random, 42 had sterilekidney-urine, while the remainder had infection ofthe kidney. (3) Bacilluria without local symptoms.In many cases this was connected with chronictoxaemia, fibrositis, aches and pains, and stiff joints ;many of the milder cases were classed as neurasthenia.

Treatment.Certain prophylactic measures might be taken

against infection from the bowel. The normalbarriers preventing the passage of bacteria seemedto be an intact epithelium, with its mucous covering,the lymph nodes in the intestinal wall, and the glandsalong the colic vessels. An acute bacilluria mightfollow drastic purgation or Plombieres treatment.Prolonged exposure to X rays and radium facilitatedthe passage of bacteria through the bowel wall, andpossibly the removal of the normal appendix might ido so also. Operations on the bowel should always beaccompanied by the administration of urinary anti-septics. The antiseptics in use were salol, boric,And hexamine. It took some time to split hexaminein contact with an acid urine and the drug was excretedunchanged in cases where there was frequency ofmicturition. Moreover, the acutely inflamed bladderwas unable to contain a very acid urine and the aciditymust be limited. In cases with an acid urine SirJohn Thomson-Walker had given up the use ofhexamine and merely tried to soothe the bladder. z,The only antiseptic which could be used in an

alkaline urine was methylene-blue, which was verymild. The intravenous injection of mercurochromeand methyhviolet, tried in America, had not fulfilledexpectations. Lavage of the renal pelvis was

the only cure in some cases, but they must bevery carefully selected ; cases of infection of theprostate or seminal vesicle or of obstruction of thelower urinary tract must be excluded, except in thepyelitis of pregnancy where the lavage seemed tohelp the condition. It was best in cases of persistentpyelitis.

Discussion and Reply.Dr. FOWLER WARD asked Prof. Dudgeon how to

distinguish between the two types of infectionclinically in order to decide whether to give vaccinetreatment or not.

Dr. J. A. ANDREWS mentioned the teeth and tonsilsas sources of infection. Certain American experi-menters had created cavities in the teeth of dogsand filled them with bacteria from the urine ofpatients and had succeeded in producing kidneylesions in a large percentage of cases.

Dr. OLIVER HEATH described a personal experienceof cystitis from which he had attempted to determinethe meaning of the symptoms experienced. Thefrequency of micturition was nature’s way of producingfrequent muscular contractions, with inflow of freshblood, bearing antibodies, and of flushing out thebladder. He had found that the discomfort could bereduced to a minimum by drinking water in excess,while the withholding of fluid rapidly producedstrangury. Treatment should be based on the sensa-tions experienced as a guide to the vis medicatrixnaturce.

’ Mr. S. G. MACDONAijD regarded acute infections bythe B. proteus as rare; they were more usually a ter-minal stage in old stricture cases. He agreed as to theassociation of calculus with staphylococcal infection.A very important group not yet mentioned were thecases with sterile urine due to renal blockage. In hisopinion surgical interference was only justified whenthere was this definite and persistent block. He askedwhere the splitting of hexamine took place as itdid not seem to occur with a damaged kidney.

Mr. H. EVERIDGE inquired whether the estimationof the cholesterol content of the blood had anypractical value in assessing the degree of infection.

Mr. GRANVILLE HEY described the case of a primi-para three months’ pregnant, who had no symptomssave a slight aching in the left loin and cloudy urine.A B. coli bacilluria was found associated with acalculus in the left kidney which was successfullyremoved. Certain American observers had demon-strated a direct continuity between the lymphatics ofthe right kidney and those of the ascending colon.The PRESIDENT described a case of granuloma of

the bowel with cystitis which had been completelycured by the intravenous injection of electrargol.Chronic B. proteus infections, in his experience, didwell with vaccine treatment but the acute ones

did not.Prof. DUDGEON, in reply, said that the examination

of a loopful of urine was insufficient; at least 10 c.cm.must be investigated before it was said to be sterile.

Sir JOHN THOMSON-WALKER, in reply, agreed thatdiuresis should always be employed as a method oftreatment. He described a case of typhoid bacilluriacleared up by removal of a stone. The splitting ofhexamine usually took place in the bladder, but itwas a matter of time. The poor results obtained byits use in cases of enlarged prostate were due to thediuresis and great dilution of the urine, so that it isimpossible to get a sufficiently high acidity for splitting,and to the condition of chronic interstitial nephritis,due to back pressure, so that less hexamine wasexcreted. Lavage would cure a certain percentage ofcases, but might fail because the patient would notcome long enough or regularly enough, or owing tothe use of an insufficiently strong antiseptic, or thepresence of a slight obstruction or small stone orpelvic dilatation. The worst type of case was a

925MEDICAL SOCIETY FOR THE STUDY OF VENEREAL DISEASES.

mixed infection with B. coli and B. proteus. Alkalinetreatment encouraged the B. proteus while acidsencouraged B. coli. If the patient happened to getan unconnected tonsil or throat infection the kidneycondition became much worse at once, though thereason for this was not known.

MEDICAL SOCIETY FOR THE STUDY OFVENEREAL DISEASES.

A MEETING of this Society was held in the roomsof the Medical Society of London on April 24th,Colonel L. W. HARRISON, the President, being in thechair.

TOXIC EFFECTS OF ARSENOBENZOL TREATMENT.

Mr. DAVID LEES opened a discussion on the toxiceffects of arsenobenzol treatment and their prevention.He said that these toxic effects, both after intravenousand intramuscular injection, were produced in manyways, and many factors entered into consideration.The chief determining factors were the health of thepatient prior to administration, the preparation ofthe patient, the drug used, the method of preparing itin solution, and the technique of administration.Physical exertion on the part of the patient, especiallyjust before or after administration, might play apart in some of the reactions that were observed.The daily regulation of the bowels, again, was essential.With regard to the drugs, the " 606 " group were moretoxic in general than the " 914," and in the case of" 606 " it was very necessary to be careful and slowin administration. Indeed, in all the drugs given forthe treatment of syphilis this slowness in administra-tion was an important factor. He was a strongbeliever in dilute solutions, and he believed also infiltration. There was no doubt that any undissolvedparticles would open the way to accidents, which mightbe avoided by using completely soluble preparations.In a great many patients psychic reactions occurredat the first administration ; they could be overcomeusually by careful technique and by having the patientin the lying posture. The fact that the beginning ofthe injection caused pain to the patient might set upfainting and other minor reactions. Some patients,no matter what precautions were taken, would reactadversely to either intravenous or intramuscularinjections of arsenic. He discussed the variousreactions, first those which occurred immediately onor after administration or within the first 24 hours,and then those which occurred later, up to a period ofmonths. In the immediate reactions were includedheadache, vomiting, and diarrhoea. It was probablethat more than one cause was present in the acutereactions which occurred after treatment with Iarsenobenzol. In his own experience, with care in the Ipreparation of the drug, and especially in the dissolvingof the drug, its filtration before use, and its slownessin administration, the incidence of the immediatereactions, both minor and major, was exceedinglysmall. Occasionally a sensitive patient was encounteredand it was necessary to consider what steps shouldbe taken to safeguard him. Mr. Lees found thatwith atropine desensitisation there was less likelihoodof the patient having cardiovascular upset than withadrenalin. Of the reactions which occurred within24 hours, skin eruptions, such as herpes and urticaria,were of little importance except as danger-signals.Special care should be taken to watch the kidneys ofsuch patients. He spoke of vasomotor disturbancesand gave particulars of cases.With regard to later reactions, albuminuria often

presented considerable difficulty. Was the albuminuriadue to drug therapy or to syphilis ? Only by waitingand watching could one possibly decide. One of themost interesting reactions was a gross exfoliatingdermatitis. There were certain individuals who hada special idiosyncrasy of the skin to therapeuticirritants, and these showed undoubtedly a greater

tendency to such a condition. From the experienceof the past ten years he could not agree with theobservation that the joint exhibition of arsenicaland mercurial therapy predisposed to the onset ofdermatitis. There was no actual proof that thedermatitis was due to over-excitation of the tissuesby metallic arsenic, as suggested by McDonagh, andone was left to assume that it was due to hyper-sensibility to arsenic on the part of the patient.Patients made a slow and uninterrupted recoveryunless complications set in. Of the complications themost dangerous was broncho-pneumonia, while otherswere peripheral neuritis and jaundice. If these com-plications could be avoided the prognosis was good.The drug most useful in the treatment of this conditionwas one of the sulphur compounds. In arsenicaldermatitis the Wassermann test frequently becamenegative and might remain negative for a considerabletime. Some workers had stated that such a patientnever again showed any manifestation of syphilis,but this he believed to be very dangerous teaching.With regard to jaundice, many considered that thiswas due to the toxic action of arsenobenzol on the livertissues. The predisposing factors were constipationand intestinal toxaemia. A very considerable numberof the mild cases of jaundice one met with were notdue to the salvarsan, although that might be a con-tributory factor, irritating, as it did, the mucous surfaceof the intestinal canal. It was a small matter forthe inflammation to extend from the bowel throughthe biliary tract and set up a liver condition. In otherwords, salvarsan was more likely to injure the liverin a person infected with syphilis who, in addition,had an intestinal toxaemia and a possible predispositionto catarrhal jaundice. For treatment, rest in bodyevacuation of the bowels, and careful dieting werenecessary, also the administration of alkalies inassociation with salicylate of soda, glucose givenintravenously, and - a diet rich in glucose. As aroutine procedure he had recently been giving 50 c.cm.of glucose by the mouth to every patient half an hourbefore treatment with arsenic. This fortified theliver against the arsenic action, and he had had veryfew cases of catarrhal jaundice.

In conclusion, he emphasised the great necessity ofcareful preparation of the patient for administrationand careful examination, especially of the urine, priorto administration. Next he emphasised care in dosageand in the technique of administration. Alcohol mustbe avoided throughout the whole course of the treat-ment. As to the amount and frequency of the drug,moderate doses should be given with a safe interval(one week), the average course of injections extendingover eight weeks and the intervals of rest eight toten weeks. Except in the early stage of the disease,heroic therapy by massive doses was not of so muchvalue as moderate, safe, and prolonged dosage. Intra-muscular administration was to be preferred to intra-venous, especially in the later stages.

Dr. J. C. BUCKLEY said that in his clinic for thefirst two years, while the novarsenobenzol was of theold " Rochester Row pattern" not a single case ofjaundice occurred, but during the last five years hehad seen about 120 cases of jaundice, all of them verymild, except one, which proved fatal, the patient dyingfour and a half months after the administration of thedrug. Of these 120 cases about 20 occurred amongpatients who had been put down as provisionally cured,having had a negative Wassermann for two years,and coming up every six months or so for a provocativedose or a test. As to dermatitis, the worst case heever saw was long before " 606

" was introduced.

Dr. T. ANWYL DAVIES thought the most importantlesson to be gathered was that the prophylacticagainst arsenical intoxication was intramuscularadministration. In addition this had greater thera-peutic value, and undoubtedly brought about anegative Wassermann sooner than did any otherform of administration.

Dr. FONVLER WARD said that he had had formerly agood many cases of stomatitis, but now he made a