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THE SECTIONS. MEDICINE.
THE BRITISH MEDICAL ASSOCIATION.
arranged
THE
approximately equivalent
energy
value, any one of which might be substituted for
BRITISH MEDICAL ASSOCIATION. EIGHTIETH ANNUAL MEETING IN LIVERPOOL.
THE SECTIONS. MEDICINE.
FRIDAY, JULY 26TH.
an
equivalent quantity of a corresponding food in the specimen"diet worked out for the patient. The ration" for protein and fatty foods was an average serving of roast beef, which weighed 3 oz. and yielded 300 calories. In some instances fractional rations were prescribed to avoid an excess of nitrogenous food being taken. Vegetables, fruits, and carbohydrate foods were similarly arranged in "rations," each of which contained 5 grammes or ’’
less of
By allowing one or more of these the natural craving for starchy food could be Dr. WILLIAM EWART (London) gave a demonstration of generally allayed, while the exact amount of carbohydrate A Systematic Posterior Percussion of the Apices, and of the taken could be adjusted to the patient’s tolerance. Household bread was usually given instead of the so-called Oval Interspinous Dulness " as ar A id to Early " diabetic"breads and bread substitutes, many of which Diagnosis. (contained as much, or almost as much, starch and were He said that the normal "oval interspinous dulness " was much more expensive, besides being difficult to obtain. In the corrected edition of the original interscapular lozenge- ( cases where nitrogenous equilibrium was easily disturbed it shaped dulnesswhich was imperfectly analysed and toowas advisable to a purely vegetable-fat diet for a loosely described in the dorsal map ’of percussion in 1899few days at regularprescribe the semi-starvation which this intervals, and again in 1910. Never unmindful of the value of a ( entailed having a beneficial effect on the patient’s powers of dorsal examination of the apices and of the lower apices and proteins. As the object of the utilising both (which would also be briefly considered) the author’s previous1treatment wascarbohydrate to so arrange the diet that the patient was diagnosis had hitherto lacked the elementary accuracyalways working his powers of carbohydrate and protein dependent upon a familiarity with the normal field of per-metabolism at a little below their maximum capacity, and cussion, and with the precise boundaries of its normalwas yet receiving sufficient food of a kind that he could use pulmonary resonance and of its normal mediastinal dulness. to supply the energy he needed, constant supervision was These could now be defined by the pleximeter in their normal for some time. The urine should therefore be individual variations, as a guide to any abnormalities, required examined at intervals to determine the state of his metawhether respiratory (pleural, pulmonary, &c., including bolism, and the diet be readjusted according to the findings functional irregularities) or mediastinal (mainly structuraland the progress of the case. Even in mild cases of and of varied derivation). That familiarity was indispensable a regulation of the diet was advisable, glycosuria for the earliest diagnosis of apical tuberculosis by physical for there wasquantitative no hard-and-fast line between these and cases signs, although this was only a small section of the general of a more severe type, the fundamental error being the same diagnostic usefulness of the new sign. For apex diagnosis thein both, and the one gradually merging into the other. The most valuable peculiarity of the oval subresonant dulness was earlier treatment could be commenced therefore the better the normal respiratory oscillation of its edges with inspirationwas the prognosis. and expiration. This afforded a standard wherewith to gauge The PRESIDENT discussed the subject. the normal, or the deficient respiratory activity of the apex, Salvarsan in Syphilis. the latter being the earliest of all morbid events in phthisis. It was also a test for the "functional"" or the "structural"" T. W. GIBBARD, R.A.M.C., communicated his Major significance of any apical inexpansion. Again, it was theexperience in 1911 with salvarsan, showing its rapidity and test between "local lesionsand indispensable differential efficiency of action in combination with mercury. He now local atelectasis."" Its close study opened up an importantgave the results in 162 patients treated either by salvarsan range of localising observations and of fine indications suchalone from the outset or in combination with mercury. as were alone adequate for the purpose of early diagnosis. After 6-21 months only 11 relapsed in seven months after The vicissitudes of the oval dulness under the varied respira- injection. Of 102 cases treated with mercury for 6-21 months tory affections (pulmonary emphysema, asthma, congestion, 81 relapsed in the course of 4.22 months. Salvarsan aborted bronchitis, the pneumonias, the pleurisies and pneumo- syphilis in the primary stage in 99 per cent., no relapses thorax, &c.) were a vast subject to which only a cursory occurring. Of 56 primary cases only two showed secondary review could be given. The mediastinal aspect of the same symptoms, while of 23 such cases treated by mercury study, that of the intensifications and of the encroachments 21 showed secondary symptoms. Among 1562 cases treated of the dulness of the oval patch, was yet more varied in its by salvarsan injection there had been no untoward results scope ; and this included an extensive surgical range of and he had seen no affections of cranial nerves. He diagnosis. The chief medical representatives in that advanced the opinion that such complications were due group were the cardiac, the pericardial, the vascular, the to relapse of syphilis and not to the remedy. About oesophageal, the neoplastic, and lastly, almost comparable 150 deaths had been recorded in the literature among in its numerical incidence with the group of phthisis, the 1,000,000 subjects, which were due to faulty technique or glandular. All of them reacted also upon the behaviour of the ignoring of well-known contra-indications. Some deaths the retrovascular dulness," of which the oval patch was had occurred within a few days after a second injection in the upward continuation. The practical conclusions were the early secondary stage, associated with punctiform hæmorsummed up in one statement: The method was indispensable rhages in the brain. They probably resulted from the for efficiency in apical and in mediastinal diagnosis. Its presence of spirochætæ in the meninges, and indicated practice was a necessity ; and this involved the unavoidable cumulative effect of arsenic in these cases. Similar results followed overdosage in rabbits. Major Gibbard advocated adoption of the means which were essential to its success. Dr. S. H. HABERSHON criticised the paper. two doses or more of salvarsan, with intramuscular injection Dr. P. J. CAMMIDGE (London) read a paper on of mercurial cream in the interval : for instance, 0’3 gramme salvarsan, two injections of calomel cream, followed by a The Quantitative Regulation of the Diet in Diabetes. He said that the diet in diabetes must be so arranged that second 0.33 gramme of salvarsan. Neosalvarsan gave better the patient received a sufficient amount of food to supply the results in doses of 1’2 grammes. The effect was similar, but there was less reaction and it was more soluble. It had the energy he needed without overtaxing his powers of metaof being very unstable and had to be used bolism in any direction. This could be satisfactorily disadvantage fresh. quite accomplished only by a quantitative as well as a qualitative The paper was discussed by the PRESIDENT, Dr. J. regulation. In many instances it was found that a limitation TAYLOR (Chester-le-Street), Mr. H. DE C. WOODCOCK of the proteins was quite as necessary as of the carbohydrates, and that mere restriction of the starch and sugar foods was (Leeds), and Mr. ARTHUR J. EvANS (Liverpool). Dr. D. J. A. CHOWRY-MUTHU (Mendip Hills Sanatorium) not sufficient to control the glycosuria. The exact proportion of each type of foodstuff that best suited the patient must be read a paper on The Treatment of Pulmonary Tuberculosis by Continuozcg experimentally determined, and he must be taught that these no no must be more and consumed Antiseptic Inhalation. each less, quantities, day. To prevent the diet becoming monotonous the author had He said that having lived both in the East and in the West worked out a system in which the various foods were he made bold to say that where there was no civilisation President, Professor T.
R. GLYNN
(Liverpool).
a
.
1
’
in "rations"of
445
day
carbohydrate.
THE BRITISH MEDICAL ASSOCIATION.
446
: there was no tuberculosis, but as soon as the savage, living into i the pleura, the pressure being regulated by a manoin his primitive way, adopted western civilisation and meter. Suitable cases were those without adhesions in western habits consumption, cancer, and syphilis ravaged hiswhich the tuberculous lesion predominated on one side, and country and destroyed his people. Civilised man, in hiswas actively progressive and comprised only about 3 or 4 pursuit of wealth and comfort, spent half his energy in per cent. of phthisical subjects. The pneumothorax was letting loose the demon of disease, and the other half in maintained by refilling at intervals of seven or eight weeks trying to catch him. The two main objects of the treat- till the disease subsided. Clear fluid often appeared and ment of consumption should be to strengthen the soil and sometimes pus, constituting a hydro-pneumothorax, but this increase the resisting power of the tissues, and every remedy was aspirated when fresh nitrogen was introduced. Four would fail that did not keep these two objects in view. cases were described, one with a temperature of 1070 F. and During many years’ sanatorium treatment in England he had another with severe laryngitis, showing the improvement in treated at least 1000 cases of consumption, and had tried condition and gain in weight with subsidence of active almost every known remedy-intravenous injection of disease which occurred at once. Dr. C. LILLINGSTON (Gorleston-on-Sea) discussed the formalin, tuberculin treatment both subcutaneously and by mouth, creosote, carbonate of guaiacol, hypophosphites, subject. cod-liver oil, &c.-and all had failed to effect a satisfactory Dr. F. RUFENACHT WALTERS (Crooksbury Sanatorium) in and permanent cure. Three main lines of treatment had a paper on saved about 50 per cent. of lives of all those treated in The Estimation of General Improvement io2 Pulmonary the sanatorium. They were : (1) open-air measures ; (2) 111tbermtlosis graduated exercises ; (3) continuous antiseptic inhalation. suggested a convenient scale for the measurement of general 1. Fresh air, food, and rest prepared the way, and was the towards recovery in pulmonary tuberculosis. basis of all treatment of consumption. 2. The rationale of Anatomical considerations, he said, were insufficient for this graduated labour was that rest and exercise were so and it was proposed to measure the general improvepurpose, and the that for regulated by adjusted physician every toxin generated in the system nature created an immunity mentin febrile cases by temperature, pulse-rate, and weight,’ which increased the resistance capacity of the patient and and in the afebrile by the amount of exercise which could be made for healing. At the Mendip Hills Sanatorium the taken without constitutional disturbance. At the CrooksSanatorium such patients undertook graduated exercise graduated exercises were worked in four groups: (a) bury Graduated breathing and singing exercises, to open up the according to a scale of 36°, grouped into 11 classes with 11 In the first group (W) walking air cells, expand the chest, and increase the intake of corresponding tests. in the second exercise, (X) carrying, in the third (Y) oxygen. (b) Graduated labour. Patients began with chopping and fourth work or games of several grades, and (Z) then to then went on wood. wood, sawing, planing They amounts were undertaken. With three classes in digging broken ground, and finally digging unbroken ground. forincreasing the febrile and 11 for the afebrile it was possible Graduated from half to miles a then five (c) day, walking to state the condition on admission and on tramping and going further afield. (d) Camping. Tramping departure with general some approach to accuracy. Cases led to camp in the open air; patients took their own food and with complications were similarly grouped but separately, slept away from the sanatorium. 3. Dr. Chowry-Muthu had grave disturbance of the digestive functions (amongst others) treated patients with continuous antiseptic inhalation since regarded as a complication. 1V testswalking on 1895, when he treated the first patient with inhalations of being level or slightly undulating ground; WA up to 2 kilocarbolic acid, creosote, and iodine. He got well, and had metres in half an hour ; WB up to 6 kilometres; WC up now a large family of grown children. Since 1899, when to 12 kilometres ; WD up to 18 kilometres, in correspondhe opened his first sanatorium, he had used the inhalation times. X tests:carrying earth or stones up an incline in a more systematic way, and had treated in this way over ing 1 in 11 for 50 metres, returning with an empty basket. of the first batch in of patients treated 500 patients. Some two hours, 12 journeys to the 1899 were still living. He had devised an inhaler, and used XA : 5 kilogramme loads for loads for 3 hours, 16 journeys hour. XB : 7t kilogramme two or three kinds of solutions, so that the patients should to the hour. XC : 10 kilogramme loads for 4 hours, not get tired of using only one kind and to suit their 20 journeys to the hour, in each case completing the four The chief ingredients were : ’ individual idiosyncrasy. hours with walking if necessary. Y and Z tests:work of formalin, iodine, terebine, pumidine, pine, chloroform and wood the thickness of rectified spirit. He felt sure that antiseptic inhalation did various grades. Second grade:chopping the or small spade in already broken wrist, rake, hoe, using enter the air-cells and destroy the activity and growth of Third grade :cutting small boughs with an axe, using the pathogenic organism. In some cases the improvement ground. an ordinary spade or fork in already broken ground, or pushing had been so marked that he could not attribute it to a loaded barrow along level ground a distance of 50 metres. anything else. His results for 1911 were : of 42 treated Fourth grade :Cutting trunks with an axe, planing wood, from 3 to 10 months, 20 got quite well (no physical signs or fork in new ground, deep digging pickaxe, using spade, and no tubercle bacilli) ; 6 greatly improved ; 5 moderately or loading a cart or pushing a full wheelbarrow up an improved; 6 improved; 4 went back; and 1 died from incline. YA : Two hours of second grade and four hours of hæmoptysis. Of the 42 patients, 24 (20 of the first and 4 third. YB: One hour of second, two hours of third, and three of the second division) had gone back to work and were hours of the fourth grade. ZA: Two hours of third and four doing umub well. hours of fourth grade. ZB : Six hours of the fourth grade. Dr. PARSONS (Gibraltar) read a paper on In training patients it was found advisable to introduce more Tuberculin in the Diagraosi.s and Treatment of Tuberculous variety than in the tests, and to allow some overlapping of Diseases, especially Pulmonary Tuberculosis. the different kinds of exercise. By the adoption of a system His contention was that, whether in diagnosis or treatment, like the foregoing it should be possible to agree upon a small doses of tuberculin could not be relied upon. definition as to what should constitute slight, moderate, or 0.01 gramme of T.R. attained by degrees was the standard great general improvement respectively, and to determine dose, but until this had been reached absence of reaction the value of different forms of treatment more accurately could not be relied upon as excluding the disease, and it than at present. Dr. W. MACAFEE, Dr. J. R. LOGAN, Dr. H. W. GARDNER needed to be exceeded in many cases, even to 1 gramme, to the about where disease was established. (Shrewsbury), Mr. WOODCOCK, and Dr. G. A. CRACE. bring recovery The open-air treatment effected most in mixed infections CALVERT (Ruthin Sanatorium) discussed the subject. Dr. W. GORDON (Exeter) read a paper on by reducing the septic element, but for eradication of tubercle itself the specific treatment was necessary, and a Further Experience of the Cardiac Sign in Cancer. combination of the two was desirable in advanced cases. Further experience, he said, confirmed the view that the .The paper was based on an experience of 27 patients, 24 cardiac sign was of practical value in the diagnosis of cancer. of phthisis, 2 lupus, and 1 mastoid disease. It consisted in a diminution of the cardiac dulness, in Dr. S. VERE PEARSON (Mundesley Sanatorium), in a paper recumbency, on digital percussion. In that posture, instead on as normally in the adult, beginning above about the third The Production of Artificial Pneumothorax in the Treatment of of, costal cartilage, reaching rightwards to about the midUoiiaterccl Tuberculous Disease of the Lungs, sternal line, and measuring across about 3 to 3! inches at exhibited an apparatus for producing artificial pneumo1 See THE thorax by the introduction of measured quantities of nitrogen LANCET, July 20th, 1912, p. 153.
progress
vv
i,
L. D.
being
THE BRITISH MEDICAL ASSOCIATION.
447
the fifth costal cartilage level, the dulness, in the cancer second stricture nearer the cardiac end, a wide excision had patient who presented the sign, began above at the fourth to be performed. Cases with many adhesions presented or fifth cartilage, had its right margin half an inch or an ’— special difficulties in the performance of excision. Mr. E. W. HEY GROVES (Bristol) suggested that the solution inch to the left of the mid-sternal line, and measured across less than 2 inches at the fifth cartilage. Often it measured of the difficulties of such cases as those under discussion was Sometimes there was no cardiac to be found in first performing a gastro-enterostomy. and then less than 1 inch across. dulness at all. As digital percussion depended much at a subsequent period the excision could be done with comon personal factors, these were his personal findings with paratively little risk. The fact that many apparently inflammoderately light percussion. Others might assign different matory lesions had already become the starting point of limits. The sign might be due to (1) small heart (often malignant disease was one of the strongest reasons of absent); (2) a sort of emphysema due to lessened lung excising all these doubtful ulcers. Mr. DOBSON, in reply, said that he would restrict excision elasticity (often present); and (3) a flabby imperfectly filled heart, such as the flabby skeletal muscles and toneless to cases in a fairly good general condition. small pulse suggested; and this would seem the chief Mr. DE COURCEY WHEELER read a paper on mechanism of the phenomenon, for a cardiac dulness The Surgery of the Sacro-iliac Joint. reduced almost to vanishing in recumbency in cancer might In the first place it was pointed out that there was no be found actually broader than normal in the erect position. It was obvious, of course, that if ordinary emphysema was synovial cavity, all disease beginning in the bones. The was thickly covered by muscles and big present a small cardiac dulness was of no significance, and, posterior aspect the but outer was covered only by the gluteus if albuminuria, valvular heart disease, or retracted lung ligaments, Doubt was thrown medius and a thin shell of iliac bone. were present, absence of the reduction in dulness was also on the existence of the classical symptoms in any but cases Less but unimportant. obviously, apparently usually, too advanced for surgical treatment. In early cases such upward displacement of the heart or the existence of a large as sciatica radiating into the lumbar region, restricted signs behind it the of the dulness. diminution growth prevented Yet allowing for these limitations to its usefulness, a very movement, especially in turning, and the radiogram ought to lead to correct Without surgical treatment large number of cases remained in which it was of value. recovery was very rare.diagnosis. were shown illustrating Lantern slides Thus, adding present cases to those published in 1908, he the and notes of three cases treated by operation suggested, had found that amongst cases which might have been cancerous In one, a man aged 40, sciatic pain and raised 93 cancer cases showed the sign in 87 per cent., and 89 non- it were read. temperature began the symptoms, and after some time an cancerous cases showed the sign only in 19 per cent., X ray photograph showed a focus of sacro-iliac joint disease. results in of the another cases 98 or, stating way, showing A small bony abscess was opened and after scraping was filled the sign, 82 per cent. were cancerous, and of 88 cases not with bismuth paste. This was followed by good recovery. the were non-cancerous. That 85 cent. sign, per showing method of operating was as follows. The point of attack the sign was not merely an expression of wasting was The on the bone was on the outer surface of the ilium midway since it was found in non-cancerous evident, rarely (a) between the sacro-sciatic notch and the posterior third of the wasting, even extreme-he had never seen it, for instance, iliac crest. The joint was opened by a burr worked by a in diabetes, even in absence of albuminuria ; (b) in cancerous brace. wasting, even when extreme, it was sometimes absent ; revolving Mr. P. NEWBOLT (Liverpool) related a case in Mr. Alfred (e) in cases of cancer which had not wasted at all it was Willett’s practice illustrating the urgent necessity for more sometimes present ; and (d) the diminution of the dulness methods in the treatment of sacro-iliac disease. radical in cancer did not seem to be proportional to the wasting. few in his But Subclavian Aneurysm. cases had been series. out of 4 6, Operable gave the sign, and it aided early diagnosis. Properly used, Mr. NEWBOLT related the case of a successful treatment it should rarely cause mistake. It had several times saved of a left subclavian aneurysm in a woman. Syphilitic him from mistakes into which others, well fitted to judge, was present. The sternal end of the clavicle was history but unacquainted with it, had fallen. Sarcoma seemed less removed and the first part of the subclavian artery tied often to cause it. If present where cancer might exist, the with two silk ligatures. Recovery had been good, and the diagnosis of cancer should be rejected only after very careful patient was shown. consideration. If absent, and the case were an early one, The PRESIDENT spoke in favour of the use of Lister’s its absence must not be given much weight, but if the case, sulpho-chromic catgut. supposing it to be cancer at all, must be a late one, the Mr. A. FULLERTON (Belfast) related instances in which absence of the sign would strengthen the opinion that the he had tied the femoral and the subclavian arteries with case was non-cancerous. ____
catgut.
Mr. C. H. FAGGE (London) also spoke of personal experiSURGERY. ence of the use of No. 3 catgut for ligature of such largevessels as the external iliac, subclavian, or axillary. He had FRIDAY, JULY 26TH. for many years discarded the use of silk entirely. President, Professor RUSHTON PARKER (Liverpool), Mr. P. J. FREYER (London) read a paper on Mr. J. F. DOBSON (Leeds) read a paper on 1000 Cases of Total Enucleation of the Enlarged Prostate. The Treatment of Gastric Ulcer by Excision and Partial He said that three of the original four cases, which he had Gastrectomy. Ulcers of the lesser curvature or body of the stomach, he first published 11 years ago, were still alive and well, and said, gave poor results after mere gastro-enterostomy. This had recently written to him expressing their gratitude. An had led the speaker to adopt the method of excision for analysis of the whole series showed: age 49 to 90-average these cases. In many instances, of which some were quoted, 69 ; weight of prostate, oz. to 17 oz. ; deaths, 54 = 5! per such cases after gastro-enterostomy suffered either from cent. All other cases were completely successful. Mortality stenosis or fatal haemorrhage. In five cases excision had had diminished from 10 per cent. in first 100 to 3 per cent. been perfectly satisfactory. In one case adhesions after in the last 100. In only about half the fatalities was death excision required subsequent gastro-enterostomy. In four due to the operation, the majority of the rest were due ta cases recurrence of ulceration took place, and in one of uræmia resulting from kidney disease. He denied that the these fatal perforation occurred. In two, a secondary cases that recovered would ever be anything but complete gastro-enterostomy was followed by complete recovery. In and absolute successes. one case the recurrent ulceration was in a fresh site on the Mr. C. A. MORTON (Bristol) asked about late results in cases. anterior gastric wall, but in all others it was in the scar of the first ulcer. This showed that it was wiser to perform a gastro-enterostomy as well as the excision. In four cases this had been done. In all the results had been perfect, both in recovery and freedom from symptoms. Mr. W. 1. DE COURCEY WHEELER (Dublin) thought that the immediate mortality of such an operation as had been described made it a doubtful alternative to gastro-enterostomy. In a woman, aged 30, with pyloric stenosis and a
of
malignant disease.
’
FULLERTON asked whether any distinction in. was to be made between fibrous and adenomatous cases. He had operated on 60 cases with 7 deaths. Mr. H. A. BALLANCE (Norwich) asked whether in complicated septic cases any special modification of the technicshould be used. In his opinion a penneal drain was often useful. Mr. HEY GROVES expressed great appreciation forMr.
operating
arranged
THE
approximately equivalent
energy
value, any one of which might be substituted for
BRITISH MEDICAL ASSOCIATION. EIGHTIETH ANNUAL MEETING IN LIVERPOOL.
THE SECTIONS. MEDICINE.
FRIDAY, JULY 26TH.
an
equivalent quantity of a corresponding food in the specimen"diet worked out for the patient. The ration" for protein and fatty foods was an average serving of roast beef, which weighed 3 oz. and yielded 300 calories. In some instances fractional rations were prescribed to avoid an excess of nitrogenous food being taken. Vegetables, fruits, and carbohydrate foods were similarly arranged in "rations," each of which contained 5 grammes or ’’
less of
By allowing one or more of these the natural craving for starchy food could be Dr. WILLIAM EWART (London) gave a demonstration of generally allayed, while the exact amount of carbohydrate A Systematic Posterior Percussion of the Apices, and of the taken could be adjusted to the patient’s tolerance. Household bread was usually given instead of the so-called Oval Interspinous Dulness " as ar A id to Early " diabetic"breads and bread substitutes, many of which Diagnosis. (contained as much, or almost as much, starch and were He said that the normal "oval interspinous dulness " was much more expensive, besides being difficult to obtain. In the corrected edition of the original interscapular lozenge- ( cases where nitrogenous equilibrium was easily disturbed it shaped dulnesswhich was imperfectly analysed and toowas advisable to a purely vegetable-fat diet for a loosely described in the dorsal map ’of percussion in 1899few days at regularprescribe the semi-starvation which this intervals, and again in 1910. Never unmindful of the value of a ( entailed having a beneficial effect on the patient’s powers of dorsal examination of the apices and of the lower apices and proteins. As the object of the utilising both (which would also be briefly considered) the author’s previous1treatment wascarbohydrate to so arrange the diet that the patient was diagnosis had hitherto lacked the elementary accuracyalways working his powers of carbohydrate and protein dependent upon a familiarity with the normal field of per-metabolism at a little below their maximum capacity, and cussion, and with the precise boundaries of its normalwas yet receiving sufficient food of a kind that he could use pulmonary resonance and of its normal mediastinal dulness. to supply the energy he needed, constant supervision was These could now be defined by the pleximeter in their normal for some time. The urine should therefore be individual variations, as a guide to any abnormalities, required examined at intervals to determine the state of his metawhether respiratory (pleural, pulmonary, &c., including bolism, and the diet be readjusted according to the findings functional irregularities) or mediastinal (mainly structuraland the progress of the case. Even in mild cases of and of varied derivation). That familiarity was indispensable a regulation of the diet was advisable, glycosuria for the earliest diagnosis of apical tuberculosis by physical for there wasquantitative no hard-and-fast line between these and cases signs, although this was only a small section of the general of a more severe type, the fundamental error being the same diagnostic usefulness of the new sign. For apex diagnosis thein both, and the one gradually merging into the other. The most valuable peculiarity of the oval subresonant dulness was earlier treatment could be commenced therefore the better the normal respiratory oscillation of its edges with inspirationwas the prognosis. and expiration. This afforded a standard wherewith to gauge The PRESIDENT discussed the subject. the normal, or the deficient respiratory activity of the apex, Salvarsan in Syphilis. the latter being the earliest of all morbid events in phthisis. It was also a test for the "functional"" or the "structural"" T. W. GIBBARD, R.A.M.C., communicated his Major significance of any apical inexpansion. Again, it was theexperience in 1911 with salvarsan, showing its rapidity and test between "local lesionsand indispensable differential efficiency of action in combination with mercury. He now local atelectasis."" Its close study opened up an importantgave the results in 162 patients treated either by salvarsan range of localising observations and of fine indications suchalone from the outset or in combination with mercury. as were alone adequate for the purpose of early diagnosis. After 6-21 months only 11 relapsed in seven months after The vicissitudes of the oval dulness under the varied respira- injection. Of 102 cases treated with mercury for 6-21 months tory affections (pulmonary emphysema, asthma, congestion, 81 relapsed in the course of 4.22 months. Salvarsan aborted bronchitis, the pneumonias, the pleurisies and pneumo- syphilis in the primary stage in 99 per cent., no relapses thorax, &c.) were a vast subject to which only a cursory occurring. Of 56 primary cases only two showed secondary review could be given. The mediastinal aspect of the same symptoms, while of 23 such cases treated by mercury study, that of the intensifications and of the encroachments 21 showed secondary symptoms. Among 1562 cases treated of the dulness of the oval patch, was yet more varied in its by salvarsan injection there had been no untoward results scope ; and this included an extensive surgical range of and he had seen no affections of cranial nerves. He diagnosis. The chief medical representatives in that advanced the opinion that such complications were due group were the cardiac, the pericardial, the vascular, the to relapse of syphilis and not to the remedy. About oesophageal, the neoplastic, and lastly, almost comparable 150 deaths had been recorded in the literature among in its numerical incidence with the group of phthisis, the 1,000,000 subjects, which were due to faulty technique or glandular. All of them reacted also upon the behaviour of the ignoring of well-known contra-indications. Some deaths the retrovascular dulness," of which the oval patch was had occurred within a few days after a second injection in the upward continuation. The practical conclusions were the early secondary stage, associated with punctiform hæmorsummed up in one statement: The method was indispensable rhages in the brain. They probably resulted from the for efficiency in apical and in mediastinal diagnosis. Its presence of spirochætæ in the meninges, and indicated practice was a necessity ; and this involved the unavoidable cumulative effect of arsenic in these cases. Similar results followed overdosage in rabbits. Major Gibbard advocated adoption of the means which were essential to its success. Dr. S. H. HABERSHON criticised the paper. two doses or more of salvarsan, with intramuscular injection Dr. P. J. CAMMIDGE (London) read a paper on of mercurial cream in the interval : for instance, 0’3 gramme salvarsan, two injections of calomel cream, followed by a The Quantitative Regulation of the Diet in Diabetes. He said that the diet in diabetes must be so arranged that second 0.33 gramme of salvarsan. Neosalvarsan gave better the patient received a sufficient amount of food to supply the results in doses of 1’2 grammes. The effect was similar, but there was less reaction and it was more soluble. It had the energy he needed without overtaxing his powers of metaof being very unstable and had to be used bolism in any direction. This could be satisfactorily disadvantage fresh. quite accomplished only by a quantitative as well as a qualitative The paper was discussed by the PRESIDENT, Dr. J. regulation. In many instances it was found that a limitation TAYLOR (Chester-le-Street), Mr. H. DE C. WOODCOCK of the proteins was quite as necessary as of the carbohydrates, and that mere restriction of the starch and sugar foods was (Leeds), and Mr. ARTHUR J. EvANS (Liverpool). Dr. D. J. A. CHOWRY-MUTHU (Mendip Hills Sanatorium) not sufficient to control the glycosuria. The exact proportion of each type of foodstuff that best suited the patient must be read a paper on The Treatment of Pulmonary Tuberculosis by Continuozcg experimentally determined, and he must be taught that these no no must be more and consumed Antiseptic Inhalation. each less, quantities, day. To prevent the diet becoming monotonous the author had He said that having lived both in the East and in the West worked out a system in which the various foods were he made bold to say that where there was no civilisation President, Professor T.
R. GLYNN
(Liverpool).
a
.
1
’
in "rations"of
445
day
carbohydrate.
THE BRITISH MEDICAL ASSOCIATION.
446
: there was no tuberculosis, but as soon as the savage, living into i the pleura, the pressure being regulated by a manoin his primitive way, adopted western civilisation and meter. Suitable cases were those without adhesions in western habits consumption, cancer, and syphilis ravaged hiswhich the tuberculous lesion predominated on one side, and country and destroyed his people. Civilised man, in hiswas actively progressive and comprised only about 3 or 4 pursuit of wealth and comfort, spent half his energy in per cent. of phthisical subjects. The pneumothorax was letting loose the demon of disease, and the other half in maintained by refilling at intervals of seven or eight weeks trying to catch him. The two main objects of the treat- till the disease subsided. Clear fluid often appeared and ment of consumption should be to strengthen the soil and sometimes pus, constituting a hydro-pneumothorax, but this increase the resisting power of the tissues, and every remedy was aspirated when fresh nitrogen was introduced. Four would fail that did not keep these two objects in view. cases were described, one with a temperature of 1070 F. and During many years’ sanatorium treatment in England he had another with severe laryngitis, showing the improvement in treated at least 1000 cases of consumption, and had tried condition and gain in weight with subsidence of active almost every known remedy-intravenous injection of disease which occurred at once. Dr. C. LILLINGSTON (Gorleston-on-Sea) discussed the formalin, tuberculin treatment both subcutaneously and by mouth, creosote, carbonate of guaiacol, hypophosphites, subject. cod-liver oil, &c.-and all had failed to effect a satisfactory Dr. F. RUFENACHT WALTERS (Crooksbury Sanatorium) in and permanent cure. Three main lines of treatment had a paper on saved about 50 per cent. of lives of all those treated in The Estimation of General Improvement io2 Pulmonary the sanatorium. They were : (1) open-air measures ; (2) 111tbermtlosis graduated exercises ; (3) continuous antiseptic inhalation. suggested a convenient scale for the measurement of general 1. Fresh air, food, and rest prepared the way, and was the towards recovery in pulmonary tuberculosis. basis of all treatment of consumption. 2. The rationale of Anatomical considerations, he said, were insufficient for this graduated labour was that rest and exercise were so and it was proposed to measure the general improvepurpose, and the that for regulated by adjusted physician every toxin generated in the system nature created an immunity mentin febrile cases by temperature, pulse-rate, and weight,’ which increased the resistance capacity of the patient and and in the afebrile by the amount of exercise which could be made for healing. At the Mendip Hills Sanatorium the taken without constitutional disturbance. At the CrooksSanatorium such patients undertook graduated exercise graduated exercises were worked in four groups: (a) bury Graduated breathing and singing exercises, to open up the according to a scale of 36°, grouped into 11 classes with 11 In the first group (W) walking air cells, expand the chest, and increase the intake of corresponding tests. in the second exercise, (X) carrying, in the third (Y) oxygen. (b) Graduated labour. Patients began with chopping and fourth work or games of several grades, and (Z) then to then went on wood. wood, sawing, planing They amounts were undertaken. With three classes in digging broken ground, and finally digging unbroken ground. forincreasing the febrile and 11 for the afebrile it was possible Graduated from half to miles a then five (c) day, walking to state the condition on admission and on tramping and going further afield. (d) Camping. Tramping departure with general some approach to accuracy. Cases led to camp in the open air; patients took their own food and with complications were similarly grouped but separately, slept away from the sanatorium. 3. Dr. Chowry-Muthu had grave disturbance of the digestive functions (amongst others) treated patients with continuous antiseptic inhalation since regarded as a complication. 1V testswalking on 1895, when he treated the first patient with inhalations of being level or slightly undulating ground; WA up to 2 kilocarbolic acid, creosote, and iodine. He got well, and had metres in half an hour ; WB up to 6 kilometres; WC up now a large family of grown children. Since 1899, when to 12 kilometres ; WD up to 18 kilometres, in correspondhe opened his first sanatorium, he had used the inhalation times. X tests:carrying earth or stones up an incline in a more systematic way, and had treated in this way over ing 1 in 11 for 50 metres, returning with an empty basket. of the first batch in of patients treated 500 patients. Some two hours, 12 journeys to the 1899 were still living. He had devised an inhaler, and used XA : 5 kilogramme loads for loads for 3 hours, 16 journeys hour. XB : 7t kilogramme two or three kinds of solutions, so that the patients should to the hour. XC : 10 kilogramme loads for 4 hours, not get tired of using only one kind and to suit their 20 journeys to the hour, in each case completing the four The chief ingredients were : ’ individual idiosyncrasy. hours with walking if necessary. Y and Z tests:work of formalin, iodine, terebine, pumidine, pine, chloroform and wood the thickness of rectified spirit. He felt sure that antiseptic inhalation did various grades. Second grade:chopping the or small spade in already broken wrist, rake, hoe, using enter the air-cells and destroy the activity and growth of Third grade :cutting small boughs with an axe, using the pathogenic organism. In some cases the improvement ground. an ordinary spade or fork in already broken ground, or pushing had been so marked that he could not attribute it to a loaded barrow along level ground a distance of 50 metres. anything else. His results for 1911 were : of 42 treated Fourth grade :Cutting trunks with an axe, planing wood, from 3 to 10 months, 20 got quite well (no physical signs or fork in new ground, deep digging pickaxe, using spade, and no tubercle bacilli) ; 6 greatly improved ; 5 moderately or loading a cart or pushing a full wheelbarrow up an improved; 6 improved; 4 went back; and 1 died from incline. YA : Two hours of second grade and four hours of hæmoptysis. Of the 42 patients, 24 (20 of the first and 4 third. YB: One hour of second, two hours of third, and three of the second division) had gone back to work and were hours of the fourth grade. ZA: Two hours of third and four doing umub well. hours of fourth grade. ZB : Six hours of the fourth grade. Dr. PARSONS (Gibraltar) read a paper on In training patients it was found advisable to introduce more Tuberculin in the Diagraosi.s and Treatment of Tuberculous variety than in the tests, and to allow some overlapping of Diseases, especially Pulmonary Tuberculosis. the different kinds of exercise. By the adoption of a system His contention was that, whether in diagnosis or treatment, like the foregoing it should be possible to agree upon a small doses of tuberculin could not be relied upon. definition as to what should constitute slight, moderate, or 0.01 gramme of T.R. attained by degrees was the standard great general improvement respectively, and to determine dose, but until this had been reached absence of reaction the value of different forms of treatment more accurately could not be relied upon as excluding the disease, and it than at present. Dr. W. MACAFEE, Dr. J. R. LOGAN, Dr. H. W. GARDNER needed to be exceeded in many cases, even to 1 gramme, to the about where disease was established. (Shrewsbury), Mr. WOODCOCK, and Dr. G. A. CRACE. bring recovery The open-air treatment effected most in mixed infections CALVERT (Ruthin Sanatorium) discussed the subject. Dr. W. GORDON (Exeter) read a paper on by reducing the septic element, but for eradication of tubercle itself the specific treatment was necessary, and a Further Experience of the Cardiac Sign in Cancer. combination of the two was desirable in advanced cases. Further experience, he said, confirmed the view that the .The paper was based on an experience of 27 patients, 24 cardiac sign was of practical value in the diagnosis of cancer. of phthisis, 2 lupus, and 1 mastoid disease. It consisted in a diminution of the cardiac dulness, in Dr. S. VERE PEARSON (Mundesley Sanatorium), in a paper recumbency, on digital percussion. In that posture, instead on as normally in the adult, beginning above about the third The Production of Artificial Pneumothorax in the Treatment of of, costal cartilage, reaching rightwards to about the midUoiiaterccl Tuberculous Disease of the Lungs, sternal line, and measuring across about 3 to 3! inches at exhibited an apparatus for producing artificial pneumo1 See THE thorax by the introduction of measured quantities of nitrogen LANCET, July 20th, 1912, p. 153.
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the fifth costal cartilage level, the dulness, in the cancer second stricture nearer the cardiac end, a wide excision had patient who presented the sign, began above at the fourth to be performed. Cases with many adhesions presented or fifth cartilage, had its right margin half an inch or an ’— special difficulties in the performance of excision. Mr. E. W. HEY GROVES (Bristol) suggested that the solution inch to the left of the mid-sternal line, and measured across less than 2 inches at the fifth cartilage. Often it measured of the difficulties of such cases as those under discussion was Sometimes there was no cardiac to be found in first performing a gastro-enterostomy. and then less than 1 inch across. dulness at all. As digital percussion depended much at a subsequent period the excision could be done with comon personal factors, these were his personal findings with paratively little risk. The fact that many apparently inflammoderately light percussion. Others might assign different matory lesions had already become the starting point of limits. The sign might be due to (1) small heart (often malignant disease was one of the strongest reasons of absent); (2) a sort of emphysema due to lessened lung excising all these doubtful ulcers. Mr. DOBSON, in reply, said that he would restrict excision elasticity (often present); and (3) a flabby imperfectly filled heart, such as the flabby skeletal muscles and toneless to cases in a fairly good general condition. small pulse suggested; and this would seem the chief Mr. DE COURCEY WHEELER read a paper on mechanism of the phenomenon, for a cardiac dulness The Surgery of the Sacro-iliac Joint. reduced almost to vanishing in recumbency in cancer might In the first place it was pointed out that there was no be found actually broader than normal in the erect position. It was obvious, of course, that if ordinary emphysema was synovial cavity, all disease beginning in the bones. The was thickly covered by muscles and big present a small cardiac dulness was of no significance, and, posterior aspect the but outer was covered only by the gluteus if albuminuria, valvular heart disease, or retracted lung ligaments, Doubt was thrown medius and a thin shell of iliac bone. were present, absence of the reduction in dulness was also on the existence of the classical symptoms in any but cases Less but unimportant. obviously, apparently usually, too advanced for surgical treatment. In early cases such upward displacement of the heart or the existence of a large as sciatica radiating into the lumbar region, restricted signs behind it the of the dulness. diminution growth prevented Yet allowing for these limitations to its usefulness, a very movement, especially in turning, and the radiogram ought to lead to correct Without surgical treatment large number of cases remained in which it was of value. recovery was very rare.diagnosis. were shown illustrating Lantern slides Thus, adding present cases to those published in 1908, he the and notes of three cases treated by operation suggested, had found that amongst cases which might have been cancerous In one, a man aged 40, sciatic pain and raised 93 cancer cases showed the sign in 87 per cent., and 89 non- it were read. temperature began the symptoms, and after some time an cancerous cases showed the sign only in 19 per cent., X ray photograph showed a focus of sacro-iliac joint disease. results in of the another cases 98 or, stating way, showing A small bony abscess was opened and after scraping was filled the sign, 82 per cent. were cancerous, and of 88 cases not with bismuth paste. This was followed by good recovery. the were non-cancerous. That 85 cent. sign, per showing method of operating was as follows. The point of attack the sign was not merely an expression of wasting was The on the bone was on the outer surface of the ilium midway since it was found in non-cancerous evident, rarely (a) between the sacro-sciatic notch and the posterior third of the wasting, even extreme-he had never seen it, for instance, iliac crest. The joint was opened by a burr worked by a in diabetes, even in absence of albuminuria ; (b) in cancerous brace. wasting, even when extreme, it was sometimes absent ; revolving Mr. P. NEWBOLT (Liverpool) related a case in Mr. Alfred (e) in cases of cancer which had not wasted at all it was Willett’s practice illustrating the urgent necessity for more sometimes present ; and (d) the diminution of the dulness methods in the treatment of sacro-iliac disease. radical in cancer did not seem to be proportional to the wasting. few in his But Subclavian Aneurysm. cases had been series. out of 4 6, Operable gave the sign, and it aided early diagnosis. Properly used, Mr. NEWBOLT related the case of a successful treatment it should rarely cause mistake. It had several times saved of a left subclavian aneurysm in a woman. Syphilitic him from mistakes into which others, well fitted to judge, was present. The sternal end of the clavicle was history but unacquainted with it, had fallen. Sarcoma seemed less removed and the first part of the subclavian artery tied often to cause it. If present where cancer might exist, the with two silk ligatures. Recovery had been good, and the diagnosis of cancer should be rejected only after very careful patient was shown. consideration. If absent, and the case were an early one, The PRESIDENT spoke in favour of the use of Lister’s its absence must not be given much weight, but if the case, sulpho-chromic catgut. supposing it to be cancer at all, must be a late one, the Mr. A. FULLERTON (Belfast) related instances in which absence of the sign would strengthen the opinion that the he had tied the femoral and the subclavian arteries with case was non-cancerous. ____
catgut.
Mr. C. H. FAGGE (London) also spoke of personal experiSURGERY. ence of the use of No. 3 catgut for ligature of such largevessels as the external iliac, subclavian, or axillary. He had FRIDAY, JULY 26TH. for many years discarded the use of silk entirely. President, Professor RUSHTON PARKER (Liverpool), Mr. P. J. FREYER (London) read a paper on Mr. J. F. DOBSON (Leeds) read a paper on 1000 Cases of Total Enucleation of the Enlarged Prostate. The Treatment of Gastric Ulcer by Excision and Partial He said that three of the original four cases, which he had Gastrectomy. Ulcers of the lesser curvature or body of the stomach, he first published 11 years ago, were still alive and well, and said, gave poor results after mere gastro-enterostomy. This had recently written to him expressing their gratitude. An had led the speaker to adopt the method of excision for analysis of the whole series showed: age 49 to 90-average these cases. In many instances, of which some were quoted, 69 ; weight of prostate, oz. to 17 oz. ; deaths, 54 = 5! per such cases after gastro-enterostomy suffered either from cent. All other cases were completely successful. Mortality stenosis or fatal haemorrhage. In five cases excision had had diminished from 10 per cent. in first 100 to 3 per cent. been perfectly satisfactory. In one case adhesions after in the last 100. In only about half the fatalities was death excision required subsequent gastro-enterostomy. In four due to the operation, the majority of the rest were due ta cases recurrence of ulceration took place, and in one of uræmia resulting from kidney disease. He denied that the these fatal perforation occurred. In two, a secondary cases that recovered would ever be anything but complete gastro-enterostomy was followed by complete recovery. In and absolute successes. one case the recurrent ulceration was in a fresh site on the Mr. C. A. MORTON (Bristol) asked about late results in cases. anterior gastric wall, but in all others it was in the scar of the first ulcer. This showed that it was wiser to perform a gastro-enterostomy as well as the excision. In four cases this had been done. In all the results had been perfect, both in recovery and freedom from symptoms. Mr. W. 1. DE COURCEY WHEELER (Dublin) thought that the immediate mortality of such an operation as had been described made it a doubtful alternative to gastro-enterostomy. In a woman, aged 30, with pyloric stenosis and a
of
malignant disease.
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FULLERTON asked whether any distinction in. was to be made between fibrous and adenomatous cases. He had operated on 60 cases with 7 deaths. Mr. H. A. BALLANCE (Norwich) asked whether in complicated septic cases any special modification of the technicshould be used. In his opinion a penneal drain was often useful. Mr. HEY GROVES expressed great appreciation forMr.
operating