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Colonel H. GRIER, R.A.M C., spoke in favour of intra-muscular injections in the treatment of syphilis; he hadgiven 15,000 injections and had seen no harmful results.
Dr. CHARLES BELL TAYLOR (Nottingham) consideredsyphilis to be usually a mild disease. Before the ContagiousDiseases Acts were passed not 1 per 1000 was permanentlyinvalided from the army. From 1859 to 1866 syphilis<diminished from 35 to 24 per 1000; it then rose under theAct to 38 per 1000 and then again fell. He could notrecognise the right to examine women and it was onlypossible to examine a very small proportion of the womenwho might be affected. As to intra-muscular injections hehad heard of three deaths following it.
Dr. J. L. MAXWELL (London) did not think that in thehome service there was any increase of syphilis, for in 1880there were 246 admissions per 1000 and in 1897 there were140. Therefore moral treatment was evidently of muchvalue. As to the amount of syphilis in the civil populationAn idea might be gained from the number of rejections forthis cause among candidates for the army. In 1878 151 per10,000 were rejected for venereal disease, but in 1897 only35 per 10,000 were rejected for this cause.The PRESIDENT of the section (Mr. BUTLIN) congratulated
the section on the moderation shown by the speakers. Hementioned that he had received a petition which had beenforwarded by Mrs. Bonham Carter, requesting the aid ofthe Association in obtaining an inquiry into the actualfacts. The petition had already been before the Council ofthe Association.
Surgeon-General O’DwYER, A.M.S., was sure that the Con-tagious Diseases Acts did not affect the prevalence of gonor-rhoea. At Aldershot special lavatories had been put up toenable the men to wash the genitals, but they would not makeuse of them. As to the prevention, the more comfortable thebarracks are the less likely will the men be to go outsidefor amusement. He was in favour of the intra-muscularmethod of treatment as it reduced the duration of stay inhospital by 10 per cent.Mr. A. H. WARD read a paper on
The Rational Treatment of Syphilis.He said that although no organism had been positivelyidentified as the cause of syphilis, yet it could not be doubtedthat the disease was microbic in origin. All the symptomswere due to the toxin and the rational treatment should aidthe natural cure. The following indications were mentioned:(1) to push the mercur.9, to the toleration point and keep itthere ; (2) to commence the course at the earliest possiblemoment; (3) to continue it throughout the normal periodof evolution of the disease ; (4) treatment must be
easy and unirritating ; (5) the general health mustbe attended to ; and (6) the value of water as an
adjuvant in removing the toxin. Mercury acted as
an antiseptic, but an overdose poisoned the patient andlowered his power of resistance ; therefore, great cautionshould be observed in debilitated persons. The course shouldlast two years and iodide of potassium should not be givenduring the primary or secondary stage. Zittmann’s decoc-tion was of value in debilitated cases.
Surgeon-Colonel F. H. WELCH, A.M.S., read a paper on
The Prevention of Syphilis,which was published in THE LANCET of August 12th, p. 403.
Mr. J. L. THOMAS (CardiS) read a paper on
Two Recent Opercctions upon the Gasserian Ganglion by theHartley-Krause RU1tte.
In both cases life was a misery and the pain had lasted twoor three years. In one case the bone was replaced and inthe other not. In preparing the scalp for operation he
employed sulphide of barium to remove the hair; it actedquickly and removed also the superficial epithelium. He
employed Horsley’s wax to block up the foramen rotundumand foramen ovale. In one of the cases the ganglion wasnot removed. The sense of taste persisted after the operation.Mr. Thomas also showed a Washing Tap for operatingrooms and demonstrated a simple method of irrigating theabdomen ; a thermometer placed in the rubber irrigating
, tube showed the temperature of the liquid as it entered theabdomen.At this meeting 116 members were present, including one
lady.
OBSTETRICS AND GYNÆCOLOGY,
THURSDAY. AUGUST 3RD.
The second day’s session was opened by a discussionon the
Natural Menopause compared with the Menopause producedby llemoval of the Uterine Appendages and the
Menopause produced by ]lemovat of theUterus without Removal of the
Appendages,introduced by Mr. BLAND SUTTON (London). He said itwas a striking fact that although they were familiar with thephenomena of menstruation and accepted unreservedly theview that the endometrium was the menstrual organ andthe ovary the controlling body, they were absolutely ignorantof the causes of menstruation. It was therefore necessaryat the outset to consider the relation between the ovariesand menstruation. The ovary, apart from being ovigerous,fulfilled other duties, like the secreting glands in general,for no organ was restricted to a single function. Heregarded the ovarian follicle as a modified mucous crypt andthe ovary as a ductless gland. The ovary was remarkablenot only as belonging to the class of ductless glands, butalso as belonging to the peculiar group of temporaryglands of which the thymus was the type ; its period ofactivity was coincident with menstrual life. The incidenceof menstruation denoted that the ovaries and uteruswere functional and that the individual was sexuallymature. The menstrual cycle, lasting about thirtyyears, represented the period during which the ovarieswere in full vigour. When both ovaries were completelyremoved from a sexually mature woman the result wasan abiding amenorrhoea and the individual presented otherpeculiarities characteristic of the menopause apart fromamenorrhoea, so that it was absolutely correct to speak ofthe arrest of menstruation produced by complete removal ofboth ovaries as an artificial menopause. Should a small
portion of healthy ovarian tissue remain, however, men-struation would continue unchecked and climacteric pheno-mena would be in abeyance. The uterus was subservient tothe ovaries ; it was an incubation chamber for the receptionand development of oosperms. Its chief peculiarity con-sisted in the remarkable cyclic changes exhibited duringmenstrual life by the endometrium, but it was important torealise that the part played by the uterus in menstruationwas merely secondary, for the menstrual discharge was atbest but a disagreeable accompaniment of menstruation.When from any cause a woman had no loss of blood at anatural menstrual period she usually experienced what we.conveniently called vaso-mutor disturbances, or, in the
terminology of ancient medicine, a menstrual moli-men.The normal menopause he defined as the cessationof menstruation in consequence of the natural atrophyof the secreting tissue of the ovaries. The meno-
pause was declared not only by the cessation ofa monthly flow of blood, but also by the peculiarcutaneous phenomenon known as 11 flushing and othersigns of nerve disturbance, such as irritability of mind,nervousness, and occasionally erotomania. In a small pro-portion of cases these conditions became so intensified as toresult in disaster ; in the greater number, however, thestorm quickly subsided and the genital organs graduallyentered upon what might be called the "resting-stage."The artificial menopause was something more than simplearrest of the periodical loss of blood ; as the source ofmenstruation was the endometrium removal of the uteruswas followed by permanent arrest of menstruation as surelyas permanent visual blindness ensued upon the removal ofboth eyeballs. The belief in vicarious menstruation had atlast found a place in the list of popular errors and foolishsuperstitions. Although removal of the uterus from a maturewoman produced amenorrhoea and sterility it did not inducea complete menopause. On the other hand, completeremoval of both ovaries from a sexually mature woman wasfollowed by amenorrhoea, sterility, and in a fair proportionof cases by "nushings," which latter were not met withafter removal of the uterus alone. It was with the viewof avoiding the production of an artificial menopausethat he deemed it wise to spare at least one ovarywhenever practicable in performing hysterectomy, and,further, to remove the uterus in many grave conditiors inpreference to the sacrifice of both ovaries. The rela-tion of the artificial menopause to nubility was a
525
matter of some social importance; he felt that if bothovaries had been removed there was little prospect of ahappy union and generally he advised against marriage.On the other hand, if a woman had had her uterus removedbut possessed at least one ovary she might be regarded asnubile if the intended husband clearly understood that themarriage would be sterile.Mr. STUART NAIRNE (Glasgow) said that he had performed
a considerable number of hysterectomies without removal ofthe ovaries and his experience led him to the following con-clusions. First, the shock of removal of the uterus was muchless than that of removal of both ovaries ; and secondly, theremoval of the uterus was not necessarily followed by theentire cessation of menstruation. He had no hesitation in
saying to patients that menstruation would have a chance ofcontinuing in spite of removal of the uterus and that themenopause would come on in a natural manner.Mr. J. W. TAYLOR (Birmingham) said that, speaking of the
clinical aspect of the subject, no special symptom or setof symptoms appeared to be peculiar to either of thethree varieties of menopause spoken of by Mr. BlandSutton. In his experience some of the very worst instancesof nervous and mental disturbance were met with in cases ofthe natural menopause; consequently these disturbancescould not be solely or mainly referred to removal of theovaries. He believed that the artificial menopause comparedunfavourably with that produced naturally, in the prolongedcharacter of the nervous disturbances. When removal of theuterus or ovaries was performed in early life these dis-turbances were often conspicuous by their absence; inmiddle life, however, they were often prolonged for years.The PRESIDENT of the section (Dr. GRANVILLE BANTOCK)
reminded Mr. Bland Sutton that during the reign of the
clamp in the treatment of the ovarian pedicle menstruationnot infrequently occurred through the stump of the Fallopiantube and this would seem to establish the fact that the endo-metrium was not the only source of the menstrual fluid. Hereferred to cases of removal of the uterus or appendages inwhich the sexual passion seemed to be intensified, and thelate Mr. Lawson Tait had given evidence to the same effect.Several cases had come under his notice in which menstrua-tion presenting all the normal characteristics occurred afterthe absolute removal of both ovaries and tubes.Dr. MACPHERSON LAWRIE (Weymouth) asked if Mr.
Stuart Nairne felt justified in assuring patients that afterremoval of the uterus menstruation would continue as
before. This seemed to him to be an opinion which wouldnot be endorsed by most gynaecologists, although there mightbe occasional exceptions to the rule.Mr. J. D. MALCOLM (London) agreed with the last speaker
that removal of the uterus would be expected to produce acessation of menstruation. After double ovariotomy themenopause varied greatly in severity, probably according tothe peculiarities of the patient. He had seen several casesin young women of from 17 to 23 years of age in which the
menopause had given very little trouble ; on the other hand,in one case, a young woman, aged 22 years, the menopausehad been the most severe in his experience. He also hadsome doubt as to whether complete removal of the ovariesalways produced cessation of menstruation.
Dr. CHARLES A. L. READE (Cincinnati) said that he had longbeen impressed with the fact that the menopause could notbe recognised as a physiological or pathological entity withuniform characters. On the contrary, he was convincedthat it was one of the phenomena of sexual life which neversquared itself to regular rules of conduct. The acute meno-pause produced by complete ablation of the uterineappendages was usually so stormy that he had sought tomitigate its severity by conservative measures, such as leavingpart or the whole of an ovary. He was compelled to admit,however, that frequently second operations had to be sub-sequently performed for the removal of the ovary left behind.He had therefore drifted back to the position of the lateMr. Lawson Tait who favoured the practice of bilateralablation of these organs. He regretted that Mr. BlandSutton had not considered the effect of the vaso-motordisturbances of the artificial menopause upon the haemato-genic functions. He had himself conducted a series ofobservations upon this point, but the facts ascertainedwere too meagre to justify conclusions. He was, however,convinced that there occurred a definite leucocytosis anda constant oligocbromsemia, reducing the percentage of
haemoglobin sometimes to 70.
. Mr. BLAND SUTTON, in reply, contended that wide varia-tions existed in the natural menopause within normallimits, for in some individuals it caused very slight dis-turbances while in others it was followed by a very pro-found and far-reaching upset of the nervous system. It,would be interesting to obtain statistics of the liability to>
insanity of women after an artificial menopause, in com-
parison with their liability after a normal menopause,childbirth, removal of a mamma, or amputation of a limb.That the influence of healthy ovaries was very great wasproved by the result of double oophorectomy in osteo-malacia, a proceeding which Fehling had placed upona sound basis of ascertained physiological and pathologicalfacts, and one supported by Curatulo’s observations upon thevariation in the output of phosphates in the urine of miceafter experimental removal of both ovaries. He wasat present deeply interested in the comparison of the thyroidand ovarian glands. They presented striking structuralsimilarities, their ablation profoundly modified meta-bolism as well as disturbed the vaso-motor system, andin each instance the disturbance was controlled by theadministration of thyroid and ovarian extract respectively.The liability of the two glands to pathological changes wassingularly similar-indeed, the pathological parallels of thethyroid and ovarian glands was a study to which he (Mr.Sutton) was at the present time giving close attention.
Professor BYERS (Belfast) next read a paper uponCases of Amenorrhwa Associated with Raynatld’s Disease ana
Pulmonary T7.berc2closis.He said that during the past 10 years he had met with aseries of cases presenting certain well-defined clinicalfeatures-viz. : (1) diminished or arrested menstruation (2) local symmetrical asphyxia of the extremities, a con-dition known as Raynaud’s phenomenon ; and (3) pulmonarytuberculosis. After giving details of four cases Professor
Byers proceeded to discuss the clinical phenomena morefully. 1. Amenorrhœa.-In three of the cases menstruationwas completely absent, while in one it was in abeyance for a.time but subsequently re-appeared, and then it was probablydue to delayed physical development; in one of the threeit ceased suddenly after a nervous shock and simultane-ously the local asphyxia developed. 2. Local asphyxia.-Raynaud taught that suppression or irregularity of menstrua-tion was often an exciting factor in the causation of thesymmetrical condition observed in the extremities and his(Professor Byers’s) observations supported that view. 3. Pul-
monary tuberculosis was present in all of the cases, eitherwhen the patient first consulted him or subsequently.This might have been a coincidence, but if so it was a verystriking one.
Dr. 1NGLIS PARSONS (London) read a paper entitled16 Cases of Procidentia and two of Prolapse of the Uteraus
treated by a New Method.He referred to nine cases already published in THE LANCET and was able to state that in all but one the good result hadbeen maintained. He now reported eight further cases inwhich good results had been obtained and no return of theprocidentia had occurred. He believed that this methodapplied to cases of prolapse in an early stage couldprevent procidentia from ever occurring. The principle ofthe treatment consisted in taking advantage of nature’sreparative powers. After dislocation of a joint an effusionof lymph occurred round it, which was the first step on thepart of nature to repair the damage. When the womb fellthe process was so gradual that there was no stimulusto the effusion of lymph; this stimulus could be suppliedby injecting solutions of sulphate of quinine intothe broad ligaments. He believed that the broadligaments were the principal agents in holding up theuterus and his object was to strengthen and repair them.He preferred to place the patient under an anæsthetic,although this was not a necessity. Then the vagina wascarefully disinfected, the posterior wall held down with a.
Sims’s speculum, and the anterior wall held up with a retractor.The injection was then made on each side of the cervixthrough the vaginal wall, the direction of the needle beingperpendicular to the base of the broad ligament. Theneedle employed was about an inch in length and ratherthicker than a hypodermic needle. A solution of one in fiveof sulphate of quinine in acidulated water was used andthe amount required was from 30 to 40 minims. After the
1 THE LANCET, Feb. 4th, 1899, p. 292.
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operation there was generally no pain and no rise of tempera-ture. In three or four days a definite mass of effusion couldbe felt in both fornices. A cup and stem rubber pe-saryshould be placed in position after the injection and retainedthere until the effusion was well formed, when the uteruscould no longer become displaced. It was best to keep thepatient at rest for one or two months afterwards to give timefor the consolidation of the new tissue. Dr. Parsons then
gave details of the cases operated upon by him up to thepresent time.A discussion followed in which the PRESIDENT of the
section said that he felt it was due to Dr. Inglis Parsons to state that he had done him (the President) the honour ofshowing him some of the cases referred to in his paper, andit was strong testimony to his good faith that the first casehe exhibited was a complete failure. But in several casesthe result was all that could be desired and he had to con-
gratulate Dr. Parsons upon the introduction of a method oftreatment that held out distinct promise of benefit in a verydistressing and hitherto very intractable class of cases.
Dr. WALTER TATE (London) said that he was surprised atthe permanence of the results reported by Dr. Inglis Parsons.In many cases of parametritis following delivery the exuda-tion was completely absorbed and no evidence of past inflam-mation remained. He would also like to know whether theresults were more permanent in the two cases referred to inwhich suppuration had occurred.
. Dr. INGLIS PARSONS, in reply to Dr. Tate, said he thoughtthe amount of exudation was about one-fourth of that whichoccurred in acute parametritis. In three-fourths of his casesno rise of temperature occurred and he therefore felt thathe was entitled to say that the exudation produced by theinjection was not inflammatory.
Mr. STUART NAIRNE read a paper on
A New and More Complete Method of Colporr7ta _phy.After recapitulating shortly the ordinary methods of col-porrhaphy he proceeded to describe the method which hehad devised and which gave much better results than theother methods. He called it "lateral colporrhaphy." Anincision was made in the vaginal wall on each side, startingfrom the cervix and going right through the vaginal wall.Two flaps were then turned up on each side, but no tissuewhatever was removed. A series of sutures was then passed,the needle entering first at the point nearest the cervix andpassing to the same level on the opposite side ; the suturesreached from the cervix down to the level of the externalgenitals. When tied a bridge was formed over which thecervix could hang either anteriorly or posteriorly, and thevagina was thus divided into two canals of more or lessequal capacity. The operation was hardly suitable for youngmarried women, but was of great value to those of moreadvanced age.
Dr. WALTER TATE agreed that the ordinary opera-tions were far from satisfactory and any new operationwhich offered permanent results would be welcomed. Itseemed to him that Mr. Stuart Nairne’s operation was verysimilar to the old operation, in which a longitudinal strip ofmucous membrane was removed from the anterior and
posterior walls, and an antero-posterior septum produced.
STATE MEDICINE.
FRIDAY, AUGUST 4TH.Dr. ARTHUR NEWSHOLME (Brighton) opened a discussion
on
The Means of Preventing the Spread of Infection in Ele-mentary Schools.
Increased facility of personal communication, Dr. News-holme said, greatly facilitated the spread of infectiousdiseases. This point needed to be remembered in comparingthe present with the past incidence of such diseases. Thechief infectious diseases tended to be in a higher proportionendemic and in a less proportion epidemic than in formertimes. It was not surprising that among the increased meansof personal intercommunication compulsory school attend-ance, affecting as it did the most susceptible period of life,occupied an important place. It was not necessary todiscuss the exact share taken by school attendance inthe spread of disease, more particularly of diphtheria.He had elsewhere given his reasons for regarding schoolinfection as only a minor cause of the spread of
diphtheria, as forming but one incident in a battle
which by no means determined the issue of the campaign.What were the most important measures applicable to theprevention of the spread of infection in connexion withschool life ? The first and most urgent was the provision ofprompt medical attendance upon children when they first fellill with what might prove to be an infectious complaint. The
greater part of the spread of infection in school life wascaused by the absence of diagnosis in the acute febrile stageof disease. He could not attempt to state which of the twofactors-lack of medical advice or medical advice givenunder unfavourable conditions-was the more frequentcause of mischief in schools. Together they caused anenormous amount of evil and no measures for preventingthe spread of infection by children attending school andin an infectious condition would secure complete success
which did not end both of these evil influences. Wouldthe medical inspection of scholars meet the requirementsof the case ? No doubt much good could be done by thismeans. Every medical officer of health had probablyhad the experience of picking out children desquamatingfrom scarlet fever in the class-room of an elementary school.Medical inspection could secure the exclusion of childrensuffering from such suspicious symptoms as recent otorrhoea,enlarged cervical glands, nasal discharge, and so on. Inseveral cases he had found the systematic employment ofbacteriological diagnosis of the greatest value. That theLondon School Board should during the past year haveraised objection to inspection of school children by a medicalofficer of health appeared to be a suicidal policy. But itmust be admitted that the medical inspection of schools hadonly a limited utility. The medical supervision of scholarsmight be extended to the visitation of absentees at theirhomes whenever absence was caused by illness. It did not,however, appear at present to come within the range ofpractical medical politics. At the present time they weredependent in their attempts to prevent the spread ot infec-tion in schools on (a) compulsory notification and on (b) thevoluntary information supplied by teachers and others.There was a great and constant struggle among schoolauthorities to increase their " average attendance," as theposition of the schools and the amount of monetary grantfrom the Imperial Exchequer depended upon that. It couldnot be expected, therefore, that under ordinary circum-stances teachers would furnish the medical officer of healthwith information which might lead to the exclusion of theirscholars from attendance at school. To meet this objectionhe had had during the last 18 months the following plan inoperation. The medical officer of health signed up not onlyfor the absences of patients but also of all other childrenfrom infected houses. That fact secured the cooperation ofteachers and school-attendance officers and relieved the stressof compulsory school attendance which, however necessaryon general grounds, was not infrequently the means ofspreading infection.
Dr. SIDNEY DAVIES (London) said that the exact positionof schools in spreading disease was not defined. He foundthat half of the cases of diphtheria were those of childrenwho did not attend school. The schools were in his opinionresponsible for the failure of medical officers of health tostamp out scarlet fever. Measles was also spread by theagency of the schools. Undetected and return cases ofscarlet fever were a great danger. He thought that somescheme of systematic medical inspection could be devised.The London School Board would no doubt have to alter theirpresent position of doing nothing themselves and of prevent-ing outside medical inspection.
Dr. KENWOOD (London) observed that in his opinion aconsiderable amount of infectious disease was the result ofcrowding children together into schools, hence those placesrequired careful supervision. Education at all costs shouldnot be allowed to stand in the way. The chief defect wasin the intelligerce department. Parental ignorance, indiffer-ence, and neglect could not be met except by the medicalinspection of scholars. Instead of gratuitous medical visita-tion as advocated by Dr. Newsholme he would suggest askilled medical inspector who should inspect at stated periodsin non-epidemic times, more especially with the view ofdealing with those suffering from errors in sight, faultydevelopment, over-pressure, and other diseased conditionsnot necessarily intectious. Such an officer should alsolecture to teachers on health matters and the earlysymptoms of disease, and he should be always availablefor the examination of school children set apart by teachersas requiring examination. In times of epidemic he should
