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SEROLOGICAL TESTS IN RHEUMATOID ARTHRITIS
194 micturition.
Dermatitis with excoriations both within the vagina and outside it develop and the parts involved The patient becomes become exquisitely painful. emaciated and depressed and evades society because of the penetrating smell of urine which emanates from her. No be made to close a fistula until all granulating surfaces are quite healed and complete The involution of the pelvic organs has taken place. best time to operate, provided that the general and local conditions permit, is at least three months after labour. Professor Mahfouz had found it possible to tackle almost all his cases (758 fully recorded and 210 others done at various hospitals) by the vaginal route. In the few cases in which he failed to close the fistula from below he also failed when he tried to close it from above. With both routes the cause of failure was the immobility of the bladder produced by dense infiltrations. The technique he followsis that of the original flap-
attempt should
splitting operation. He does not practise the wide separation of the bladder advised by most surgeons who use this method, but only such separation as is sufficient to prevent tension on the sutures when tied. He does not close the bladder wall by more than At the end of the operation, after closure one tier of sutures. of the vaginal flaps, he washes the bladder cavity again and leaves a catheter tied in the urethra for 10-12 days. The patients are allowed free movement in bed, and it is immaterial whether a suction apparatus is used. The sutures are removed on the 17th day.
In the lecturer’s of moderate size is
opinion the cure of a mobile fistula operation that can be successfully performed by gynaecological surgeons who have had some experience in vaginal surgery. Immobile nstulae of the vault and fistulæ tethered to the pelvic walls, as well as urethral nstulae involving the neck of the bladder, demand great experience in plastic vaginal surgery. In his early cases the failures were more common than the successes, and he sometimes had to perform the operation three or four times before effecting a cure. But his last 300 cases have all been successful, and almost always
was
agglutinating
The chemical nature of the rheumatoid factor had been finally elucidated. With Dr. Carlsson she was investigating this problem, using zone electrophoresis on a starch column. The hæmagglutinating factor came chiefly from the y-globulin fraction, and titres increased in parallel with the y-globulin concentration, but some activity was also due to a fraction in the region. Unlike y-globulin cold-precipitated globulin from rheumatoid sera scarcely moved during paper electrophoresis. The cold globulin was somehow adsorbed by the paper, and could be eluted only with difficulty. Professor Svartz went on to describe her experiments in which streptococci from throats of patients with rheumatoid arthritis were cultured on media containing connective tissue. In some cases a hsemagglutinating factor had appeared in the medium after incubation ; but this had also happened occasionallv using other bacterial species from other sources. Nevertheless, it might suggest that the rheumatoid factor was enzymic. Among drugs known to inhibit the hæmagglutinating factor in vitro the sulpha group was the most effective ; but even the most active of theseacetazolamide (’Diamox’)—was inhibitory only at levels far exceeding those obtainable in vivo. not
an
"
has been obtained at the first shot." At the end of the lecture a colour film was shown illustrating operation on several types of fistula. Mr. CHARLES READ, the president, then expressed the thanks of the college and of the large audience-many of whom could claim long friendship with the lecturer.
success
precipitated by cold, but usually the hæmfactors of other collagen diseases were not. She had found that the use of cold globulin, instead of serum, in the test reduced the proportion of both false negatives and false positives.
factor
SEROLOGICAL TESTS IN RHEUMATOID ARTHRITIS Prof. NANNA SvARTZ (Stockholm) gave the Gilbert Scott lecture at the Charterhouse Rheumatism Clinic, London, on July 17. Professor Svartz remarked that the diversity of the serological tests used in the diagnosis and management of rheumatoid arthritis underlined the need for a specific diagnostic test, especially in cases with atypical onset. Modification of the sheep-cell agglutination test had raised the proportion of positives in rheuinatoid arthritis from 40%, obtained originally by Waaler and by Rose, to about 90%. Her own method, in which the haemagglutination titres of rheumatoid sera before and after absorption with normal sheep cells were compared, gave results at about this level ; and similar results were obtained using joint fluid instead of serum. As to the nature of this rheumatoid factor, she and her colleague Dr. K. Schlossmann rejected the idea that it was an auto-antibody; they had found that it was not readily adsorbed with either sensitised or unsensitised cells, and had never obtained positive Coombs tests with positive sera ; the failure of hormone treatment to influence the titre of the serum might also be evidence against the factor being an antibody. False positive reactions (especially common in dis-
sheep
seminated lupus erythematosus) had encouraged attempts to separate the factor from serum. The rheumatoid
GENERAL MEDICAL COUNCIL MEDICAL DISCIPLINARY
COMMITTEE : JULY
17-18
THE Medical Disciplinary Committee of the council met on July 17and 18 under the chairmanship of Sir DAVID CAMPBELL, the president. JUDGMENT FURTHER POSTPONED
registered as of c/o Milne, Broxy Cottage, Westmuir, M.B. Glasg. (1935), had been stood over from the May session. Judgment had been postponed in May, 1954, May, 1955, and May, 1956, following a conviction of being drunk and disorderly and a finding by the committee that he had for a considerable period neglected his duties as a medical practitioner under the National Health The
case
of William Frank Cruickshank,
Service. Mr. G. J. K. Widgery, solicitor to the council, said that Dr. Cruickshank had been convicted on Jan. 5, 1956, at Marylebone Magistrates’ Court, after pleading guilty, of driving a motor-car when under the influence of drink, and had been fined £15, disqualified from driving for twelve months, and ordered to pay jElO 10s. costs. The committee postponed judgment until May, 1957. "
TECHNICALLY GUILTY "
"
Because, his counsel said, he was technically guilty," Cornelius O’Brien, registered as of 3, York Villas, Walton Breck Road, Liverpool, 4, M.B. N.u.i. (1943), admitted canvassing persons living in the Millpark Estate, Eastham, Cheshire, with a view to persuading such persons to become his patients. He was represented by Mr. Jack Tarsh, instructed by Berkson & Berkson, of Birkenhead. Mr. E. B. McLellan, instructed by Messrs. Le Brasseur & Oakley as solicitors to the Medical and Dental Defence Union of Scotland, appearing for the complainant, said that the housing estate had been erected within the last few years. The allegation was that from time to time Dr. O’Brien got into conversation with persons and suggested that they might consider becoming his patients, and in some cases he produced a visiting-card which gave his name, qualifications, address, and surgery hours. He gave three of these cards to a Stateregistered nurse and midwife. Mr. Tarsh said that Dr. O’Brien now realised that his behaviour came within the meaning of the word canvassing, but there were many matters which the committee should accept as greatly mitigating his behaviour. Dr. O’Brien, after qualification, started a practice in Liverpool. At first he did not practise at Eastham, but then he realised that he would be given some expense allowances if he did and therefore he
Dermatitis with excoriations both within the vagina and outside it develop and the parts involved The patient becomes become exquisitely painful. emaciated and depressed and evades society because of the penetrating smell of urine which emanates from her. No be made to close a fistula until all granulating surfaces are quite healed and complete The involution of the pelvic organs has taken place. best time to operate, provided that the general and local conditions permit, is at least three months after labour. Professor Mahfouz had found it possible to tackle almost all his cases (758 fully recorded and 210 others done at various hospitals) by the vaginal route. In the few cases in which he failed to close the fistula from below he also failed when he tried to close it from above. With both routes the cause of failure was the immobility of the bladder produced by dense infiltrations. The technique he followsis that of the original flap-
attempt should
splitting operation. He does not practise the wide separation of the bladder advised by most surgeons who use this method, but only such separation as is sufficient to prevent tension on the sutures when tied. He does not close the bladder wall by more than At the end of the operation, after closure one tier of sutures. of the vaginal flaps, he washes the bladder cavity again and leaves a catheter tied in the urethra for 10-12 days. The patients are allowed free movement in bed, and it is immaterial whether a suction apparatus is used. The sutures are removed on the 17th day.
In the lecturer’s of moderate size is
opinion the cure of a mobile fistula operation that can be successfully performed by gynaecological surgeons who have had some experience in vaginal surgery. Immobile nstulae of the vault and fistulæ tethered to the pelvic walls, as well as urethral nstulae involving the neck of the bladder, demand great experience in plastic vaginal surgery. In his early cases the failures were more common than the successes, and he sometimes had to perform the operation three or four times before effecting a cure. But his last 300 cases have all been successful, and almost always
was
agglutinating
The chemical nature of the rheumatoid factor had been finally elucidated. With Dr. Carlsson she was investigating this problem, using zone electrophoresis on a starch column. The hæmagglutinating factor came chiefly from the y-globulin fraction, and titres increased in parallel with the y-globulin concentration, but some activity was also due to a fraction in the region. Unlike y-globulin cold-precipitated globulin from rheumatoid sera scarcely moved during paper electrophoresis. The cold globulin was somehow adsorbed by the paper, and could be eluted only with difficulty. Professor Svartz went on to describe her experiments in which streptococci from throats of patients with rheumatoid arthritis were cultured on media containing connective tissue. In some cases a hsemagglutinating factor had appeared in the medium after incubation ; but this had also happened occasionallv using other bacterial species from other sources. Nevertheless, it might suggest that the rheumatoid factor was enzymic. Among drugs known to inhibit the hæmagglutinating factor in vitro the sulpha group was the most effective ; but even the most active of theseacetazolamide (’Diamox’)—was inhibitory only at levels far exceeding those obtainable in vivo. not
an
"
has been obtained at the first shot." At the end of the lecture a colour film was shown illustrating operation on several types of fistula. Mr. CHARLES READ, the president, then expressed the thanks of the college and of the large audience-many of whom could claim long friendship with the lecturer.
success
precipitated by cold, but usually the hæmfactors of other collagen diseases were not. She had found that the use of cold globulin, instead of serum, in the test reduced the proportion of both false negatives and false positives.
factor
SEROLOGICAL TESTS IN RHEUMATOID ARTHRITIS Prof. NANNA SvARTZ (Stockholm) gave the Gilbert Scott lecture at the Charterhouse Rheumatism Clinic, London, on July 17. Professor Svartz remarked that the diversity of the serological tests used in the diagnosis and management of rheumatoid arthritis underlined the need for a specific diagnostic test, especially in cases with atypical onset. Modification of the sheep-cell agglutination test had raised the proportion of positives in rheuinatoid arthritis from 40%, obtained originally by Waaler and by Rose, to about 90%. Her own method, in which the haemagglutination titres of rheumatoid sera before and after absorption with normal sheep cells were compared, gave results at about this level ; and similar results were obtained using joint fluid instead of serum. As to the nature of this rheumatoid factor, she and her colleague Dr. K. Schlossmann rejected the idea that it was an auto-antibody; they had found that it was not readily adsorbed with either sensitised or unsensitised cells, and had never obtained positive Coombs tests with positive sera ; the failure of hormone treatment to influence the titre of the serum might also be evidence against the factor being an antibody. False positive reactions (especially common in dis-
sheep
seminated lupus erythematosus) had encouraged attempts to separate the factor from serum. The rheumatoid
GENERAL MEDICAL COUNCIL MEDICAL DISCIPLINARY
COMMITTEE : JULY
17-18
THE Medical Disciplinary Committee of the council met on July 17and 18 under the chairmanship of Sir DAVID CAMPBELL, the president. JUDGMENT FURTHER POSTPONED
registered as of c/o Milne, Broxy Cottage, Westmuir, M.B. Glasg. (1935), had been stood over from the May session. Judgment had been postponed in May, 1954, May, 1955, and May, 1956, following a conviction of being drunk and disorderly and a finding by the committee that he had for a considerable period neglected his duties as a medical practitioner under the National Health The
case
of William Frank Cruickshank,
Service. Mr. G. J. K. Widgery, solicitor to the council, said that Dr. Cruickshank had been convicted on Jan. 5, 1956, at Marylebone Magistrates’ Court, after pleading guilty, of driving a motor-car when under the influence of drink, and had been fined £15, disqualified from driving for twelve months, and ordered to pay jElO 10s. costs. The committee postponed judgment until May, 1957. "
TECHNICALLY GUILTY "
"
Because, his counsel said, he was technically guilty," Cornelius O’Brien, registered as of 3, York Villas, Walton Breck Road, Liverpool, 4, M.B. N.u.i. (1943), admitted canvassing persons living in the Millpark Estate, Eastham, Cheshire, with a view to persuading such persons to become his patients. He was represented by Mr. Jack Tarsh, instructed by Berkson & Berkson, of Birkenhead. Mr. E. B. McLellan, instructed by Messrs. Le Brasseur & Oakley as solicitors to the Medical and Dental Defence Union of Scotland, appearing for the complainant, said that the housing estate had been erected within the last few years. The allegation was that from time to time Dr. O’Brien got into conversation with persons and suggested that they might consider becoming his patients, and in some cases he produced a visiting-card which gave his name, qualifications, address, and surgery hours. He gave three of these cards to a Stateregistered nurse and midwife. Mr. Tarsh said that Dr. O’Brien now realised that his behaviour came within the meaning of the word canvassing, but there were many matters which the committee should accept as greatly mitigating his behaviour. Dr. O’Brien, after qualification, started a practice in Liverpool. At first he did not practise at Eastham, but then he realised that he would be given some expense allowances if he did and therefore he