545

and opisthotonos, which only stopped when the nux vomicawas discontinued.

Dr. H. J. CAMPBELL (Bradford) read a paper on

The Treatment of Cardio-arterial Disease.Diffuse arterio-sclerosis caused a disturbance of circulationand nutrition which was temporarily compensated for bycardiac hypertrophy. After a time, however, when this hadreached its maximum, continued high arterial tension waslikely to lead to post-hypertrophic degeneration of thecardiac muscle. A correct appreciation of the degree of thistension was desirable, and Dr. Campbell was accustomed touse Hill and Barnard’s sphygmometer for that purpose andconsidered that it answeredvery well. It did not indeed recordvery well the extreme degrees of high pressure, but that wasof little moment so long as they recognised that the highpressure existed. He deprecated routine treatment in thesecases, but thought that each should be considered on its ownmerits. Harm might be done in one by treatment whichwould be quite appropriate in others. If kidney sclerosiswere also present it additionally complicated matters. Inthis case he was accustomed to rely on an exclusive diet ofmilk and large doses of sodium iodide.

Dr. FORBES Ross read a paper on the Treatment ofTuberculosis by Meat Albumin, which will be found at

p. 523.Mr. STUART-Low (London) read an unannounced paper

,on the Use of Mucin in Diseases of the Alimentary Tract,and Dr. J. HADDON (Hawick) one on a Change of Life inMen as well as in Women.Owing to the room allotted to this section having been

changed on each day it was very poorly attended on thelast day, members not being able to find it.

SURGERY.

FRIDAY, AUGUST 2ND.Mr. HOWARD MARSH (surgeon to St. Bartholomew’s

Hospital, London) opened a discussion on

Injuries of Joints, with Special Reference to their Inamediccteand Remote Treatment by Massage and Movement.

This subject, he said, was very suitable for discussion at sucha meeting as the present. Both massage and movementshave long been employed in English surgery, but lately they’have come into much more general use. Both are valuable"remedies, but if used as a matter of routine both may dogreat harm. As methods of surgical treatment they mustalways be closely supervised, care being taken to watchtheir effect, and especially to be sure that no element is

present in the case which renders their employment unde-sirable. It is necessary to have a clear idea as to what has’been termed the -physiology of massage "-as to thedifferent ways, i.e., in which it acts. 1. It enlargesthe amount of blood circulating through the partconcerned. This is obviously apparent in the skin, whichinstead of remaining cold and pale becomes warm, and’more or less red. The same result was experimentallydemonstrated in regard to the muscles by Brunton andTunnicliffe who showed that the amount of blood

passing through them both during massage and afterits cessation was increased. This increase of blood is in

- every way advantageous. It maintains or improves thenutrition of all the various tissues ; it promotes the restora-tion of the functional activity of injured muscles, and it

plays an important part in the absorption of lymph and’extravasated blood. 2. Its action is mechanical. By knead-ing and percussion extravasated blood and lymph which have coagulated in the tissues and led to brawny oedemaare broken up ,and dislodged, while by stroking frombelow upwards they are swept onwards and brought withinthe reach of healthy lymphatics and a normal venous circu-lation, so that they can more readily be absorbed. 3. It- is an efficient stimulant to damaged muscles through itsinfluence on the nervous system. In such minor injuries assprains and contusions probably the small nerves ramifyingin the injured part are seldom torn across, for they are tough-rather than brittle, they are well protected in the subcu-taneous tissue and the deeper structures, and their course isoften tortuous so that they are not easily put on the stretch. Nevertheless, they are not infrequently so far injured thattheir functions, for the time being, are more or less sus-

pended, and massage is then a very useful agent in stimu-lating them to a resumption of activity. It probably acts

in a similar manner on the vaso-motor nerves which presideover the arterial system of the part. 4. No one who haswatched its sedative effect when applied in cases ofrecent injury can doubt the influence of massage in

reducing muscular spasm and relieving pain. Here itmust be used very gently and be limited to stroking andlight friction for short periods three or four times a dav.5. Probably massage promotes the absorption of recentlyformed adhesions provided they are not too extensive andfirm. This is a matter of considerable interest. Just as

provisional callus, formed in the repair of fractures, is

absorbed, so is the new connective tissue which is developedafter injury of the soft parts. Perhaps the most obviousinstance of this is met with in the case of adhesions follow-

ing peritonitis Often even extensive adhesions gradually yetcompletely disappear, probably as the result of constant dis-turbance and traction during peristalsis. Much the sameresult is produced by what may be termed the interstitialdisturbance and traction which take place during thedifferent movements employed in massage. As to move-ments these are of three kinds : those performed under ananaesthetic, passive movements, and voluntary movements onthe part of the patient often carried out against resistance.As to movements under an anaesthetic they can be safelyapplied only when a careful diagnosis has been made. Inthe first place it must be ascertained that the joint itself isnot, nor has been, actively diseased, so that it has undergoneno considerable structural changes such as follow tubercle,or osteo-arthritis, septicaemia, or locomotor ataxia. Thecases in which this form of movement is most successful arethose in which the joint itself is practically healthy whileit is hampered by changes in the parts around. Passivemovements are chiefly useful in restoring movements thathave been lost, or in preventing stiffness in joints whichare to be long disused-for instance, a healthy ankle-the patient having disease of the hip or the knee.

Voluntary movements on the part of the patient, espe-cially when performed against resistance, are in manyinstances more valuable than massage. Several forms of

apparatus have been introduced for use in these move-ments and many of them are very satisfactory. In all cases,however, efficient supervision must be maintained. Diagnosisis, of course, of essential importance. It cannot always beexact, but it must be carried far enough to indicate that thecase belongs to the general class in which these agents areuseful and that no element is present which renders themunsuitable. The conditions for which massage and move-ments are most useful are sprains and contusions of pre-viously healthy joints unattended with any serious com-plication, such as dislocation or fracture, any widelaceration of muscle, rupture or displacement of tendons,or such pre-existent conditions as tubercle, gout, or hfemo-philia. The treatment of recent fractures by massage wasso fully discussed at the meeting last year at Ipswich that itis needless to consider it now. The after-treatment ofdislocations has of late years undergone a great and veryadvantageous change. In the case, e.g., of the shoulderthe arm is no longer bandaged to the side for a fortnight orthree weeks, but passive movements and massage are

regularly used after the second or third day. He had seen a

patient thus treated able to move his arm freely in everydirection in the course of three weeks. He had also seen a

patient walk freely and without lameness three weeks afterthe reduction of a dislocation of the hip. The chief

symptoms which indicate the use of massage and movementsare stiffness and pain ; but before they are employed thecause of the symptoms must be ascertained as to whetherthe mischief is inside or around the joints. Take theshoulder. The arm may be stiff and there may be severepain and marked muscular wasting. Is this a case ofdisease of the joint itself or of adhesions outside ? There is,he believed, only one test to be relied on to determine thisquestion. This is to ascertain whether the joint is as stiffas it at first sight appears to be, or whether, within certainlimits, movements are free and smooth. If these free andsmooth movements-limited though they be-are present thefact is a strong indication that the joint is sound and thatthe symptoms depend on surrounding adhesions. (Casesin illustration were related.) As to pain, it is veryimportant to remember that it cannot be used to differen-tiate between real joint disease and surrounding adhesions.Indeed, in many cases pain due to adhesions is more severethan that produced by joint disease. Muscular wasting-aprincipal symptom in disease of a joint-may be present

546

though the case is one of mere adhesions in the capsule andsurrounding parts. In some instances movement under ananaesthetic will produce a cure which there seemed at first

sight no reason to anticipate, for though the patient com-plains of "weakness" and pain in the joint there is no

appreciable stiffness or any condition for which movementand massage seem called for. These cases, which bone-setters’ not rarely cure by moving them as they move allothers, are instances of slight adhesions which cannot bedetected but which are yet sufficient to make the patient walkwith lameness and "weakness" of the joints concerned.

(Cases were related to illustrate this group.)Mr. R. H. A. WHITELOCKE (Oxford) spoke of the treatment

of injuries to the healthy joints of young adolescents-Oxfordathletes. He agreed with the necessity of particularity indiagnosis. In simple sprain with stretching of ligamentswhich were seen at once he was accustomed to applyelastic pressure by cotton-wool and massage, with a

result that the limb was fit for use and sport in threeweeks’ time. In slight lacerations around the joint hewas accustomed to use movement under an anaestheticto free the articular surfaces from any synovial remnants,then to apply pressure, and in 24 hours himself to movethe joint passively and gently massage, but he wouldallow no active movements until the lapse of 14 days. He

rejected the use of rigid apparatus. He remarked that he hadto deal with intelligent people who would satisfactorily con-form to the treatment. In remote injuries, such as had beentreated with rigid apparatus, he thought that adhesions wereformed by the organisation of blood-clot which always waspresent in serious strains, so that unless the movement wasearly adhesions and stiffness resulted. Often the pain andstiffness were referable to a rheumatic tendency which salicy-lates rapidly alleviated.

Mr. F. F. BURGHARD (London) agreed in the use of earlypassive movements in the shoulder-joint, &c., and the bad-ness of prolonged fixation. Movement removed the liabilityto fixation. He believed in the frequency of movementunder an anaesthetic and a gentle attempt to break down theadhesions each week rather than one vigorous attempt. Hehad formerly used elastic pressure in recent cases, but nowhe had discarded it and relied on massage alone.

Dr. J. WARD COUSINS (Portsmouth) remarked on the

necessity of treating the slight abrasions present in con-tusions around joints ; these were very liable to septicinfection in the poor.’ He believed in an immediate use ofthe antiseptic bath. He also noted the importance of slightinjuries in diathetic subjects, tubercle in the young, and

gout in the old ; for the latter he found the hot-air bathuseful. In general cases he preferred rest for a few days,then massage to the muscles and tendon sheaths, and toleave the joint itself alone. He strongly objected to theprobing of wounds around joints ; the application of anti-

septic dressings was all that was required.Mr. H. GILBERT BARLING (Birmingham) agreed that there

had been too much fixation in the past and believed in earlymovements with elastic pressure : the latter, he thought,might express accumulated fluid. He confessed he could not,like Mr. Whitelocke, get patients well in three weeks ; if hecould he would not let them then indulge in athletics, for hebelieved all such injuries to arise from a state of " out-of-condition " of the muscles. He believed it was better not touse splints in Colles’s fracture with moderate deformity ; hewould ignore the deformity and seek for mobility. Henarrated two cases of lady pianists where with no otherfixation than that of a sling with passive movements in twodays and active movement in a week he had had such goodresults that the piano could be played in three months.

Mr. J. PAUL BUSH (Bristol), referring to Mr, Whitelocke’sremarks, said that he had seen no such speedy resultsamongst the soldiers in South Africa, even in carefullyselected cases.

Mr. J. R. MORISON (Newcastle-ou-Tyne) said that he muststrike a discordant note. In talking of treatment they werein danger of forgetting pathology. To prevent inflammationwas to prevent adhesions. Many so-called injuries to jointswere not connected with the joints at all but with theirsurroundings. He used to suture with gut the fracturedpatella, not irrigate, and to rest the joint for six weeks, gettinga better result by such means than others with wiring andearly passive movements. In miners displacement of the semi-lunar cartilages was frequent and to them such a joint wasuseless without excision of the loose body ; he then gave restfor a month and got good results. When there was a definite

organic injury to a joint rest was essential. He thought thatelastic pressure was good. He noted a curious case of severe.pain in the wrist following on strain without obvious defect ;:he thought neurosis might account for it and he had pro.cured relief by heroic doses of the interrupted current.

Mr. HOWARD MARSH, in replying, said that he believed iiielastic pressure ; probably there was only support of relaxedvessels and so prevention of effusion. As regards quite earlymovements he was at issue with Mr. Morison. In some 80 to 91)-cases of excision of the semilunar cartilage he had removedthe splint in about a week when the wound was healed andcommenced massage to the muscles. In the next weekactive movements were allowed, and in the succeeding twe,or three weeks the patient was up and about, so that in twomonths he was at work again. So with the patella, but inthis case he did not allow the patient out without a knee-support for two or three months. Replying to Mr. Bnrghard,he thought that all adhesions should be broken down atone time. He agreed with Dr. Cousins regarding anti-

sepsis and with Mr. Barling regarding the connexion of

sprains with loss of muscle-tone. In cases of slipping ofthe semilunar cartilages of the knee massage should be

adopted and never plaster supports. He believed in splint-less Colles’s fracture treatment ; in cases where suchfractures turned out badly it was not from deformity per scbut from matting of structures.

Mr. F. F. BURGHARD read a paper on

171e Treatment-Non-operative and Operative-of CongenitalDislocation of the Hip.

At the outset he deprecated sweeping statements regardingthis deformity, different conditions requiring differentmeasures. Discussing the anatomical features of the-state he said that the dislocation on the dorsum ilii wasnot so invariable as was thought ; it might succeed amuch slighter displacement under the anterior superioriliac spine. The increase in the angle made by the long-axis of the femoral neck with the transverse axis of thecondyles was increased from a normal of from 25° to 300to as great as from 100° to 150° ; this twisting was suchthat the limb was rotated inwards when the head wasproperly in the acetabulum. The diminution of the.

angle of the neck with the shaft of the femur from a normalof from 110° to 140° to as little as 90° was proportional.with the length of time during which the child had walked.A point which was noted by Hoffa, to which was due theultimate failure of apparently successful operations, was

the hour-glass shape assumed by the capsule, owing to thepassage over it of the ilio-psoas tendon, and the exceedinglydense, unyielding character of the part over the acetabulum.owing to the thickening of the capsular bands. Thetreatments by the apparatus of Hoffa, of Hoffa-Mikulicz,and of Schede were discussed and their insufficiencywas shown. The bloodless or extension method ofLorenz was also shown to be in the majority of cases

a failure, even in the hands of its author. Of the opera-tive measures he gave his experience of Hoffa’s, Lane’s,and Paci’s methods, their indifferent success, and stated his.belief that the cause of this in many cases was that the headof the bone must lie over the acetabulum with a portion ofthe capsule or even ligamentum teres interposed between itand the bone. In several cases it was impossible to force thehead of the femur through the narrow capsular constriction.referred to without enlarging the orifice. He described amode of operation which had been attended with muchsuccess. At a preliminary sitting the femur was freedsufficiently to get the trochanter down to Nelaton’s line andfor abduction to 900. By a curved incision the fasciaand tensor vaginag femoris were freed from the ilium, thelimb was rotated outwards, and the capsule was incisedparallel and internal to the anterior spiral line. The tendonof the ilio-psoas was freed and the attachment of the capsule-to the front of the acetabulum and the rectus tendonwas also freed; now on manipulation by Lorenz’s methodthe head at once entered the acetabulum. All that nowremained was to excise an elliptical portion of the redundantanterior part of the capsule, which was tightly sutured bycatgut, and the joint was stable. The deep structures wereunited by one or two catgut sutures. The limb was put upin a form of Croft’s plaster splint and after a month a.

skiagram was taken, when it was seen that the head of thefemur was in excellent position. In six months the childwas allowed to walk with a thick sole on the sound side andnow, 18 months after, the child was perfectly cured and the

547

head of the bone was in place. Four other cases had been

.operated on with equal success ; all of the patients were-under six years of age. He noted the necessity of selection.of cases and their early recognition and treatment.. He con-cluded with a classification of cases in groups arranged.according to the applicability of the various methods oftreatment described.

Mr. HOWARD MARSH said that he had felt the un-

satisfactoriness of such cases though the operative pro-- cedure that had been described that day helped matters.on very satisfactorily. He- remarked that a case whichhad been much vaunted as a cure by extension had,been submitted to him without his knowledge ’ of the

previous history ; he had found the condition to bethat of an absolutely untouched congenital dislocation. He

.agreed to the frequency of dislocation under the anteriorsuperior spine. If the head was fixed in a pseudo-joint andwas not sliding he thought that operation would do no good ;it was urgently necessary where there were much displace-ment upward and backward and a sliding condition, herepatients were hopelessly lame. He remarked that the ill-

- development of the limb and muscles of such cases was a.great drawback and he noted one feature of the paper-thedefinite examination of the anatomical condition and the

operative treatment accordingly.Mr. R. H. A. WHITELOCKE read a paper on

J. Case of Hydatid of the Right Plcecrcc- successfully treatedby Operation.

The case was that of a woman, aged 28 years, a resident ofAbingdon. Symptoms of pleurisy appeared in March, 1900.In June a swelling appeared in the eighth right intercostalspace. In July she was operated upon, parts of two ribs wereresected, and the cavity was opened and drained ; the fluid’was straw-coloured and contained cysts. Cysts were dis-charged from the wound until December, when Mr. P. Martinsecured the edge of the mother cyst and drew it out entire.The points of the case were : the patient had never been outof England ; the rarity of cases under such circumstances.and especially of infection of the pleura ; also the complete absence of pulmonary symptoms.Dr. J. MICHIE (Adelaide) had frequently seen similar cases’in Adelaide ; it was not uncommon to get long-continued dis-charge of the daughter cysts.

Mr. JAMES RANKIN (Kilmarnock) read a paper describing.an operation for

Senile Gangrenein a man, aged 72 years. There was a rapidly spreading’gangrene of the foot spreading from around an ingrowingtoe-nail. The leg was amputated by Stephen Smith’s dis-;articulation at the knee by lateral flaps. The result was

perfect. The old man devised his own pin-leg and contem-plated returning to work.Mr. R. C. CHICKEN (Nottingham) read a note and showed

.a specimen ofLoose Bodies from the Enee-joint.

’The case had been undiagnosed for a long .time and wassupposed to be old-standing disease of the joint. He

suspected loose bodies, opened the joint and removed 67soft cartilaginous loose bodies, weighing together one ounce.He was inclined to think that loose bodies were more

frequently multiple than single.Dr. ELIZA L. WALKER DUNBAR (Bristol) read a paper on

Reductibility of Long-standing Dislocations.’The paper described a case of partial dislocation of the right Ihip-joint which, after existing five years, was reduced with-out difficulty under anaesthesia, showing that the joint had inno way become blocked. The patient was a woman, aged31 years. A skiagram of the case was shown. The sym-ptoms were greater length of the leg by half an inch,absence of power by everting the foot, insecurity in standingand walking, requiring assistance of a staff, and pain afterexertion. Reduction was followed by great relief and freeuse of the limb. During three years since reduction dis-location had threatened three or four times and movementhad been somewhat impeded until passive movements-thenecessity for which had been impressed on the patient at thetime of treatment -were carried out ; this restored the norma- condition. Another case, one of rarer occurrence, was

partial dislocation of the right sacro-iliac joint. The’dislocation had existed for six years, causing incessantdiscomfort and acute pain after rising from a sitting

posture and in turning round when lying down. The patientwas a woman, -aged 32 years. The dislocation, whichwas shown in a skiagram, had been produced by liftinghastily a heavy scuttleful of coal. It was reduced under anæs-thesia as shown by a skiagram and kept well in place withcomplete relief for 15 months. Then one day after walkingupstairs the patient thought that she felt the joint give way.Pain did not come on for 14 days, when the old discomfortset in. The dislocation was reduced again as soon as thepatient applied for advice. The relief was quite perfect.Both cases were treated without splint or bandage. Thefirst was massaged, whilst passive and active movementswere carried out from the first day for one month. Thesecond case was dismissed in 10 days..

STATE MEDICINE.

FRIDAY, AUGUST 2ND.

The final meeting of this section commenced with thereading of some notes by Mr. J. A. WANKLYN (London)upon

Recently examined Arsenical Beers.He held that the failure to recognise the presence of arsenicin beer to a great extent depended in the recent arsenicalepidemic on the abandonment of the original Marsh’s processand on the protean powers of combination possessed byarsenic. It was known that two grains of arsenic in theshape of arsenious acid had proved a fatal dose, but 15 grainsof arsenic in the shape of cacodylic acid or cacodylate ofsoda were not fatal, and, indeed, had been taken withoutmanifest ill effect. Mr. Wanklyn exhibited specimens of

cacodyl and cacodyl red pigment and mentioned that theywere extremely rare.

Dr. T. M. LEGGE (Inspector of Factories) addressed themeeting on the subject of

The Diseases of Occupations.He said that the anomalies in trade diseases-viz., thedifference of the symptoms produced among workers makingor using poisonous materials from those produced by theirmedicinal exhibition-were very striking. The manufactureof potassium cyanide, for example, appeared to be almost ifnot quite innocuous. In the manufacture of potassiumbichromate the lesions were limited. There was no evidencethat chromic acid dust penetrated to -the lungs. Amongstworkers with arsenic the symptoms of neuritis were absent.In hatters’ and furriers’ processes, where rabbit skins werebrushed with nitrate of mercury, salivation was rare, thoughtremor was a prominent symptom, and there was inaddition marked erosion of the teeth due to the acid fumes.There had been given no adequate explanation why thecontinued inhalation of the fumes of yellow phosphorusshould be limited to the maxillary bones, for satisfac-

tory evidence was lacking that anything in the natureof phosphorism was produced. In regard to anthraxworkers in wool, horsehair, and hide industries seemed tobear an almost charmed life. If the contention were rightthat the incidence of tetanus on jute workers was due tospores imported in incredible numbers it was surprising thatcases following on lacerated wounds in jute mills were notmore frequent ; that must be attributed to the natural

immunity of the human subject to tetanus. In factorieswhere lead was used it was right to be on guard againstattributing every case of anasmia in youthful workers to theiremployment. One of the most difficult points in industrialdisease was to estimate rightly the effect of the inhala-tion of dust on the lungs and the relation of fibroid

phthisis to true phthisis. With the exception of mineraldust containing a high percentage of silica, steel dust,flax, and of a few others evidence had not beenmade very clear of injury to the lungs from manykinds of dust. Attention was called to the pneumoniainduced by the inhalation of basic slag dust ; there wasnothing in the composition of the dust apart from its finedivision to render it particularly injurious. Referring tothe notification required of every case of lead, arsenic,phosphorus, or mercurial poisoning, and of anthrax con-

tracted in a factory, Dr. Legge pointed out that medicalpractitioners who notified cases of lead-poisoning from drink-ing water or in a house-painter engaged entirely in outsidework might’think it pedantic to draw a distinction betweennotifiable and non-notifiable lead-poisoning, but the wholepoint of the distinction was to obtain a clue only to those