- Email: [email protected]
NORTH OF ENGLAND OBSTETRICAL AND GYNÆCOLOGICAL SOCIETY.
759 LONDON ASSOCIATION OF
MEDICAL WOMEN’S FEDERATION.
very difficult to trace
only two had been
lost
them, especially in London,. sight of.
Dr. H. CHAMBERS pointed out that a final decision to the most suitable technique could only be made after years of trial. But the work of Prof. S. Russ< on experimental animals had been most helpful He had inserted tubes of radium and then excised!a,. piece of the tumour after varying intervals, testing the viability of the portion excised by transplantation into another animal. In this way the range of effect, which was the most important factor to’ be considered, could be estimated. Dr. Chambers showed diagrams of the various methods used in different clinics, explaining that the method of inserting a tube into the cervix without any other tubes in the vault of the vagina could not be adequate over a sufficient area. She explainedthe importance of distributing the tubes, since the range of effect did not exceed half an inch. Soft rays had low penetrating power and caused local sloughing, hence the need for screening. The ideal aimed at was the disappearance of the growth with the minimum damage to healthy tissues, and gamma rays appeared to be the most useful agent available for this purpose. Prof. LouisE McIfROY congratulated the Association on the first piece of organised research undertaken by medical women as a group. She commented on the fact that patients in early stages often omit to tell their doctors of the symptoms, since these may be very slight, perhaps a little haemorrhage and no pain, even when the growth has reached the inoperable stage. For the last two years Prof. McIlroy had ceased operating on cases of cancer of the cervix, using radium instead, with what appeared so far to be excellent results. It was important to disseminate the knowledge that non-operative treatment was available since this might lead patients to seek advice as
Radium Treatment of Uterine Cancer. of this Association was held on March 27th at the house of the B.M.A., Miss ELIZABETH BOLTON, the President, being in the chair. Miss M. CHADBUBN gave an account of the work undertaken by the Cancer Research Subcommittee since its formation in 1925. It had been decided to concentrate on radium treatment of uterine cancer. The committee had spent the first few months studying technique, and continental clinics had been visited in order that different methods and results could be compared. Dr. Hurdon, the research officer for whose services a grant was given by the Radiological Committee of the Medical Research Council and the British Empire Campaign, had done magnificent work under great difficulties. The treatment was given at the four hospitals-the Royal Free Hospital, South London Hospital for Women, Elizabeth Garrett Anderson Hospital, and the New Sussex Hospital for Women-staffed by women, in cooperation with Dr. Hurdon, who advised them as to technique and followed up cases after treatment. The need for concentrating the work in one centre was becoming more and more apparent, though some cases would still be treated at these hospitals even when the ideal of a central institute had been achieved. It was estimated that 210,000 would suffice to make a modest beginning, and members of the association were urged to attempt to collect this sum. Dr. Hu,norr pointed out that during the last few years radium had largely taken the place of surgery in the treatment of cancer occurring in accessible situations. In the Mayo and certain other clinics radium was now used exclusively for cancer of the cervix, even in operable cases. Statistics over a term of years would be necessary before the comparative results could be estimated, but at present it looked as if the practice of radiotherapy would increase. Dosage was now becoming standardised and for the most part adequate doses were given. Dr. Hurdon referred to figures given by Dr. J. Lane-Claypon in her survey of the subject, published by the Ministry of Health. Over a period extending to five years after treatment the results of operation and of radium were about the same-40 per cent. of nonrecurrences, whereas radium gave an additional 12 per cent. in cases which were inoperable when first seen. Unfortunately more than half of the patients presented themselves when the growth was already inoperable, usually six to nine months after symptoms had first been noticed. In the series of cases treated by the committee of the Women’s Medical Federation only 15 per cent. were operable when first seen. As to technique, a modification of that used by Heyman, of Stockholm, was adopted, since on the whole his results over long periods seemed to be better than those of others. Many continental clinics used this technique, though in France and Italy that of Regaud seemed to be more favoured. It was too early yet to make any claims for the final outcome of treatment in the cases under Dr. Hurdon’s observation, but the following results were of interest. 188 cases had started treatment during the period October, 1925, to April, 1928. Of these, 169 were cases of cancer of the cervix, 15 of cancer of the corpus, and four of cancer of tre vagina or vulva ; 70 per cent. of these cases were living in March, 1928, 30 per cent. being dead. Of the operable cases over 95 per cent. were living and free from symptoms. The immediate mortality of treatment by radium was nil, but certain complications might occur subsequently, such as fistulae, rectal ulcer or rectal pain, tenesmus, and the passage of blood or mucus. These complications were happily rare-for example, fistulae attributable to radium had occurred in only two cases in the series under discussion. The following up of patients was most important. Though it was A
MEETING
earlier. Miss G. DaABNLBY said that the improvement in general health after radiotherapy had struck her She had removed one uterus after treatment and no. trace of growth could be found even microscopically. Miss L. MARTINDALE said that more- beds were: urgently required. It was often embarrassing to find for patients to return to hospital for the requisite three doses.
room
__
NORTH OF ENGLAND OBSTETRICAL AND
GYNÆCOLOGICAL SOCIETY. A MEETING of this Society was held at Liverpool March 16th, Dr. LEITH MURRAY, the President, in the chair. A paper on Cystoseopy in Carcinoma of the Cervix, based on a study of 111cases, was. read by Dr. A. A GEMMELL (Liverpool). He described the method employed to determine clinically the operability of cases of cervical cancer, and pointed out that " " " " cystoscopy added sight to touch in estimating anterior extension. The appearances seen were‘ described, in their order of gravity, as being: (I}p bulging of the floor of the bladder ; (2) circulatory changes ; (3) transverse ridging ; (4) oedema-(a) diffuse, (b) bullous; (5) desquamation ; and (6) on
malignant invasion-(a) ulcerative, (b) hypertrophic. There were also other and rarer changes. Dr. Gemmell insisted that the lesions
seen
were
not
pathognomonic of carcinoma of the cervix, but were nevertheless important when seen just behind the trigone. All his findings had been checked by pathological examination of the growths. In a few instances in which it had been possible to do a second cystoscopy, the order of severity of the appear-
mentioned had been confirmed. The bladder of the patients had been -investigated, and it had been shown that in both operable and inoperable groups approximately 50 per cent. of patients had no urinary symptoms, whilst 30 per cent. complained of frequency. It seemed, therefore, that bladder symptoms were no guide to the degree of ances
symptoms
760 bladder involvement. in
operable
cases
The appearances of the bladder
(39) and inoperable
cases
(72)
were
recounted. Five cases, clinically classed as operable but by cystoscopy classed as inoperable, were found Of seven on further investigation to be inoperable. borderline cases, five were submitted to operation only because the cystoscopic findings were favourable, and their after-histories had justified the interference. It was concluded that early transverse ridging was the sign which denoted the limit of operability. The appearances of the ureteric orifices were no guide to the difficulties likely to be encountered in their dissection, and catheterisation of the ureters was advised for this purpose. In order to determine whether the bladder was adherent to the cervix, Dr. Gemmell recommended the following manoeuvre. Before the introduction of the cystoscope, a volsellum forceps is attached to the cervix. While the retrotrigone is being inspected, traction is put on these forceps. When there is no attachment between the cervix and the bladder, the former is seen to slide behind the latter ; where attachment exists the bladder wrinkles up. He concluded by discussing the pathology underlying the abnormal signs in the bladder, and quoted figures suggesting a connexion between the cystoscopic appearances and prognosis. The PRESIDENT said that he knew from personal experience the value of cystoscopic examination as an aid to judging operability in carcinoma of the cervix. Mr. ROBERT KENNON (Liverpool) congratulated Dr. Gemmell on his intensive cystoscopic study of carcinoma of the cervix, and especially on his interesting observation that with the cystoscope early adhesion to the bladder could be detected by following the movements of the cervix, reacting to the drag A sign so simple should be on a volsellum forceps. of wide application and value. Transverse ridging and bullous oedema, if in the retrotrigonal area of the bladder, had a grave significance. Prof. MILES PHILLIPS (Sheffield) said that he had found the cystoscope very useful in these cases, and agreed that- the ridge and furrow appearance was a sign that the limits of operability had been reached. Mr. F. A. G. JEANS (Liverpool) agreed that the appearance of the ureteric orifices was no guide to the condition of the ureters in relation to extension of the growth. A number of cases were described.
Reviews and Notices of Books. PHYSICAL CONSTITUTION
MENTAL DISEASE. Significance of Physical Constitution in Mental Disease. Medicine Monographs. By F. L. WERTHEIMER, Associate in Psychiatry, Phipps Psychiatric Clinic; and FLORENCE E. HESKETH, Charlton Fellow in Medicine, Johns Hopkins University. London : Bailliere, Tindall and Cox ; Baltimore : Williams and Wilkins Company. 1926. Pp. 87. lls. 6d. THIS monograph deals with the study of 65 male patients chosen at random from the Phipps Clinic and the State Hospital, and classed into four diagnostic groups, those predominantly affective (manic depressive), schizophrenic reaction types, organic reaction types, and psychopathic personalities and psychoneuroses. They were studied from two main standpoints, first by observation of various bodily features as a basis for grouping into types mainly following those of Kretschmer, and secondly, according to anthropometric methods, measurements being taken of 53 values following the technique of Martin and Hrdlicka ; the attempt was then made to see whether the latter values, or indexes derived from them, could be correlated with the former, and either or both with the mental abnormality. From frequency distribution curves no indication of bimodal or trimodal frequency was found, and no morphological types were found to emerge from the anthropometric measurements. The indices commonly used are unsuitable for mental patients, whose frequent changes of weight interfere with their value. The authors advocate the use of a new index using skeletal points alone, consisting of- 3 leg length x 10 100 X Transverse chest X sagittal chest x trunk height They do not, however, give exact directions for the taking of these measurements. This index is based on the idea that the relation of trunk volume to limb length may be correlated with morphological types; and it was found to correlate well with the type distribution obtained by observation, the high index values corresponding to the asthenic type and a predominantly schizophrenic mental reaction, while the low index values appear in the pyknic types and The importance of the manic depressive cases. considering age-incidence in such studies is emphasised, this being an important source of error. The authors suggest using the terms syntropic and for the groups of prepsychotic personalities tending to correspond with the morphological types, ROBB’S NURSERY BISCUITS AND BISCUITi instead of Kretschmer’s cycloid and schizoid, which unduly stress an uncertain relationship to psychosis. POWDER. out that premature correlation of such (ALEC ROBB AND Co. LTD., ATKINS-ROAD, CLAPHAM PARK, They point types with endocrinology is unwise until more accurate LONDON.) THIS well-known product can be used, mixed with knowledge is available. The introductory chapter on history of the study of types is particularly milk, as a food for infants from 6 or 7 months of age, the and as a nourishing and sustaining food for invalids valuable. and persons of weak digestion. The powder is prepared from the biscuits, and when analysed the CLINICAL PATHOLOGY. following results were obtained:Second edition. By P. N. PANTON, M.A., M.B., Per cent. Clinical Pathologist to the London Hospital and Director of the Clinical Laboratories ; and J. R. MABBACK, M.A., M.D., Chemical Pathologist to London : J. and A. the London Hospital. Churchill. 1927. Pp. 459. 16s.
Reports
and
IN
the
Analytical Records. idiotropic
.
_____
The last-mentioned figure supports the claim of the makers as to the easy and complete digestibility of the biscuits, which are crisp and pleasantly flavoured. When used according to the directions given, the biscuits or powder constitute a useful and valuable
foodstuff.
THIS volume is long overdue. Time was when Panton and Clinical Pathology were almost synonymous in the mind of the average medical student ; but 15 years is a long while between editions, and in these latter days the inflow of works on the subject from the west can only have been equalled by the outflow of gold in the opposite direction. The present volume is a worthy successor to the first edition, and the association of Dr. Marrack with Dr. Panton is a recognition of the growing importance of chemical
MEDICAL WOMEN’S FEDERATION.
very difficult to trace
only two had been
lost
them, especially in London,. sight of.
Dr. H. CHAMBERS pointed out that a final decision to the most suitable technique could only be made after years of trial. But the work of Prof. S. Russ< on experimental animals had been most helpful He had inserted tubes of radium and then excised!a,. piece of the tumour after varying intervals, testing the viability of the portion excised by transplantation into another animal. In this way the range of effect, which was the most important factor to’ be considered, could be estimated. Dr. Chambers showed diagrams of the various methods used in different clinics, explaining that the method of inserting a tube into the cervix without any other tubes in the vault of the vagina could not be adequate over a sufficient area. She explainedthe importance of distributing the tubes, since the range of effect did not exceed half an inch. Soft rays had low penetrating power and caused local sloughing, hence the need for screening. The ideal aimed at was the disappearance of the growth with the minimum damage to healthy tissues, and gamma rays appeared to be the most useful agent available for this purpose. Prof. LouisE McIfROY congratulated the Association on the first piece of organised research undertaken by medical women as a group. She commented on the fact that patients in early stages often omit to tell their doctors of the symptoms, since these may be very slight, perhaps a little haemorrhage and no pain, even when the growth has reached the inoperable stage. For the last two years Prof. McIlroy had ceased operating on cases of cancer of the cervix, using radium instead, with what appeared so far to be excellent results. It was important to disseminate the knowledge that non-operative treatment was available since this might lead patients to seek advice as
Radium Treatment of Uterine Cancer. of this Association was held on March 27th at the house of the B.M.A., Miss ELIZABETH BOLTON, the President, being in the chair. Miss M. CHADBUBN gave an account of the work undertaken by the Cancer Research Subcommittee since its formation in 1925. It had been decided to concentrate on radium treatment of uterine cancer. The committee had spent the first few months studying technique, and continental clinics had been visited in order that different methods and results could be compared. Dr. Hurdon, the research officer for whose services a grant was given by the Radiological Committee of the Medical Research Council and the British Empire Campaign, had done magnificent work under great difficulties. The treatment was given at the four hospitals-the Royal Free Hospital, South London Hospital for Women, Elizabeth Garrett Anderson Hospital, and the New Sussex Hospital for Women-staffed by women, in cooperation with Dr. Hurdon, who advised them as to technique and followed up cases after treatment. The need for concentrating the work in one centre was becoming more and more apparent, though some cases would still be treated at these hospitals even when the ideal of a central institute had been achieved. It was estimated that 210,000 would suffice to make a modest beginning, and members of the association were urged to attempt to collect this sum. Dr. Hu,norr pointed out that during the last few years radium had largely taken the place of surgery in the treatment of cancer occurring in accessible situations. In the Mayo and certain other clinics radium was now used exclusively for cancer of the cervix, even in operable cases. Statistics over a term of years would be necessary before the comparative results could be estimated, but at present it looked as if the practice of radiotherapy would increase. Dosage was now becoming standardised and for the most part adequate doses were given. Dr. Hurdon referred to figures given by Dr. J. Lane-Claypon in her survey of the subject, published by the Ministry of Health. Over a period extending to five years after treatment the results of operation and of radium were about the same-40 per cent. of nonrecurrences, whereas radium gave an additional 12 per cent. in cases which were inoperable when first seen. Unfortunately more than half of the patients presented themselves when the growth was already inoperable, usually six to nine months after symptoms had first been noticed. In the series of cases treated by the committee of the Women’s Medical Federation only 15 per cent. were operable when first seen. As to technique, a modification of that used by Heyman, of Stockholm, was adopted, since on the whole his results over long periods seemed to be better than those of others. Many continental clinics used this technique, though in France and Italy that of Regaud seemed to be more favoured. It was too early yet to make any claims for the final outcome of treatment in the cases under Dr. Hurdon’s observation, but the following results were of interest. 188 cases had started treatment during the period October, 1925, to April, 1928. Of these, 169 were cases of cancer of the cervix, 15 of cancer of the corpus, and four of cancer of tre vagina or vulva ; 70 per cent. of these cases were living in March, 1928, 30 per cent. being dead. Of the operable cases over 95 per cent. were living and free from symptoms. The immediate mortality of treatment by radium was nil, but certain complications might occur subsequently, such as fistulae, rectal ulcer or rectal pain, tenesmus, and the passage of blood or mucus. These complications were happily rare-for example, fistulae attributable to radium had occurred in only two cases in the series under discussion. The following up of patients was most important. Though it was A
MEETING
earlier. Miss G. DaABNLBY said that the improvement in general health after radiotherapy had struck her She had removed one uterus after treatment and no. trace of growth could be found even microscopically. Miss L. MARTINDALE said that more- beds were: urgently required. It was often embarrassing to find for patients to return to hospital for the requisite three doses.
room
__
NORTH OF ENGLAND OBSTETRICAL AND
GYNÆCOLOGICAL SOCIETY. A MEETING of this Society was held at Liverpool March 16th, Dr. LEITH MURRAY, the President, in the chair. A paper on Cystoseopy in Carcinoma of the Cervix, based on a study of 111cases, was. read by Dr. A. A GEMMELL (Liverpool). He described the method employed to determine clinically the operability of cases of cervical cancer, and pointed out that " " " " cystoscopy added sight to touch in estimating anterior extension. The appearances seen were‘ described, in their order of gravity, as being: (I}p bulging of the floor of the bladder ; (2) circulatory changes ; (3) transverse ridging ; (4) oedema-(a) diffuse, (b) bullous; (5) desquamation ; and (6) on
malignant invasion-(a) ulcerative, (b) hypertrophic. There were also other and rarer changes. Dr. Gemmell insisted that the lesions
seen
were
not
pathognomonic of carcinoma of the cervix, but were nevertheless important when seen just behind the trigone. All his findings had been checked by pathological examination of the growths. In a few instances in which it had been possible to do a second cystoscopy, the order of severity of the appear-
mentioned had been confirmed. The bladder of the patients had been -investigated, and it had been shown that in both operable and inoperable groups approximately 50 per cent. of patients had no urinary symptoms, whilst 30 per cent. complained of frequency. It seemed, therefore, that bladder symptoms were no guide to the degree of ances
symptoms
760 bladder involvement. in
operable
cases
The appearances of the bladder
(39) and inoperable
cases
(72)
were
recounted. Five cases, clinically classed as operable but by cystoscopy classed as inoperable, were found Of seven on further investigation to be inoperable. borderline cases, five were submitted to operation only because the cystoscopic findings were favourable, and their after-histories had justified the interference. It was concluded that early transverse ridging was the sign which denoted the limit of operability. The appearances of the ureteric orifices were no guide to the difficulties likely to be encountered in their dissection, and catheterisation of the ureters was advised for this purpose. In order to determine whether the bladder was adherent to the cervix, Dr. Gemmell recommended the following manoeuvre. Before the introduction of the cystoscope, a volsellum forceps is attached to the cervix. While the retrotrigone is being inspected, traction is put on these forceps. When there is no attachment between the cervix and the bladder, the former is seen to slide behind the latter ; where attachment exists the bladder wrinkles up. He concluded by discussing the pathology underlying the abnormal signs in the bladder, and quoted figures suggesting a connexion between the cystoscopic appearances and prognosis. The PRESIDENT said that he knew from personal experience the value of cystoscopic examination as an aid to judging operability in carcinoma of the cervix. Mr. ROBERT KENNON (Liverpool) congratulated Dr. Gemmell on his intensive cystoscopic study of carcinoma of the cervix, and especially on his interesting observation that with the cystoscope early adhesion to the bladder could be detected by following the movements of the cervix, reacting to the drag A sign so simple should be on a volsellum forceps. of wide application and value. Transverse ridging and bullous oedema, if in the retrotrigonal area of the bladder, had a grave significance. Prof. MILES PHILLIPS (Sheffield) said that he had found the cystoscope very useful in these cases, and agreed that- the ridge and furrow appearance was a sign that the limits of operability had been reached. Mr. F. A. G. JEANS (Liverpool) agreed that the appearance of the ureteric orifices was no guide to the condition of the ureters in relation to extension of the growth. A number of cases were described.
Reviews and Notices of Books. PHYSICAL CONSTITUTION
MENTAL DISEASE. Significance of Physical Constitution in Mental Disease. Medicine Monographs. By F. L. WERTHEIMER, Associate in Psychiatry, Phipps Psychiatric Clinic; and FLORENCE E. HESKETH, Charlton Fellow in Medicine, Johns Hopkins University. London : Bailliere, Tindall and Cox ; Baltimore : Williams and Wilkins Company. 1926. Pp. 87. lls. 6d. THIS monograph deals with the study of 65 male patients chosen at random from the Phipps Clinic and the State Hospital, and classed into four diagnostic groups, those predominantly affective (manic depressive), schizophrenic reaction types, organic reaction types, and psychopathic personalities and psychoneuroses. They were studied from two main standpoints, first by observation of various bodily features as a basis for grouping into types mainly following those of Kretschmer, and secondly, according to anthropometric methods, measurements being taken of 53 values following the technique of Martin and Hrdlicka ; the attempt was then made to see whether the latter values, or indexes derived from them, could be correlated with the former, and either or both with the mental abnormality. From frequency distribution curves no indication of bimodal or trimodal frequency was found, and no morphological types were found to emerge from the anthropometric measurements. The indices commonly used are unsuitable for mental patients, whose frequent changes of weight interfere with their value. The authors advocate the use of a new index using skeletal points alone, consisting of- 3 leg length x 10 100 X Transverse chest X sagittal chest x trunk height They do not, however, give exact directions for the taking of these measurements. This index is based on the idea that the relation of trunk volume to limb length may be correlated with morphological types; and it was found to correlate well with the type distribution obtained by observation, the high index values corresponding to the asthenic type and a predominantly schizophrenic mental reaction, while the low index values appear in the pyknic types and The importance of the manic depressive cases. considering age-incidence in such studies is emphasised, this being an important source of error. The authors suggest using the terms syntropic and for the groups of prepsychotic personalities tending to correspond with the morphological types, ROBB’S NURSERY BISCUITS AND BISCUITi instead of Kretschmer’s cycloid and schizoid, which unduly stress an uncertain relationship to psychosis. POWDER. out that premature correlation of such (ALEC ROBB AND Co. LTD., ATKINS-ROAD, CLAPHAM PARK, They point types with endocrinology is unwise until more accurate LONDON.) THIS well-known product can be used, mixed with knowledge is available. The introductory chapter on history of the study of types is particularly milk, as a food for infants from 6 or 7 months of age, the and as a nourishing and sustaining food for invalids valuable. and persons of weak digestion. The powder is prepared from the biscuits, and when analysed the CLINICAL PATHOLOGY. following results were obtained:Second edition. By P. N. PANTON, M.A., M.B., Per cent. Clinical Pathologist to the London Hospital and Director of the Clinical Laboratories ; and J. R. MABBACK, M.A., M.D., Chemical Pathologist to London : J. and A. the London Hospital. Churchill. 1927. Pp. 459. 16s.
Reports
and
IN
the
Analytical Records. idiotropic
.
_____
The last-mentioned figure supports the claim of the makers as to the easy and complete digestibility of the biscuits, which are crisp and pleasantly flavoured. When used according to the directions given, the biscuits or powder constitute a useful and valuable
foodstuff.
THIS volume is long overdue. Time was when Panton and Clinical Pathology were almost synonymous in the mind of the average medical student ; but 15 years is a long while between editions, and in these latter days the inflow of works on the subject from the west can only have been equalled by the outflow of gold in the opposite direction. The present volume is a worthy successor to the first edition, and the association of Dr. Marrack with Dr. Panton is a recognition of the growing importance of chemical