913

BRITISH MEDICAL ASSOCIATION.

ANNUAL MEETING IN EASTBOURNE.

SECTION OF DERMATOLOGY.

AT the second session Mr. A. DICKSON WRIGHTopened a discussion on

Varicose Ulcer.

He said should the veins become incompetent toreturn the blood to the heart, stagnation phenomenawould result. The region in which ulcers developedvaried according to the type of footwear. Thename varicose ulcer was not comprehensive enough,because many of the ulcers had other causes, and asthe final cause in all cases was gravity, a better namewas " gravitational ulcer." In the treatment of all-ulcers of the leg constant support was essential.In addition it must be such as not to involvehospitalisation, and it must not be too expensive ;it must be simple and within the reach of all medicalpractitioners, and not too laborious and time-

consuming. It was of the utmost importance thatthe treatment should not be left to out-patient ordistrict nurses. The treatment the speaker adopted 1was to support the leg with a bandage of elastic stick-ing-plaster, which could not move when once applied,and could be wound on smoothly in a continuousspinal. In large ulcers skin-grafts were buried in thegranulations by insinuation of small implants, bydarning in threads of skin, or by injecting suspensionof skin in saline ; but this made no difference to themethod of dressing, the elastic sticking bandage beingused just the same. Varicose veins were treated byinjections of sodium morrhuate and ligature of

large penetrating veins, and venous cysts were treatedin some cases. These ligatures were performed in theout-patient department, as the whole treatment mustbe ambulatory. There were only two contra-indica-tions-associated arterial disease and diabetes.Failure in the treatment was nearly always due tolooseness of the bandage. Eczema developed in,5 per cent. of cases, and in about 1 per cent. became

generalised. Blisters also developed under the

bandage and caused a fair amount of pain anddischarge. He never stopped treatment on thisaccount, and had only once had to abandon treatmenton account of eczema. Cutting of the bandage intothe skin produced linear ulceration and was dueto faulty bandaging. It could be avoided by placinglongitudinal strips up the legs as splints. Pain wassometimes increased at first by the pressure ; to avoidthis the speaker said he used sorbo rubber pads, withadhesive on one side, and pressed into the floor of theulcer. He had also found aspirin powder, sprinkledon the floor of the ulcer, a valuable analgesic whoseeffect lasted four to seven days.

Mr. Wright gave details of the successful treatmentof two difficult cases, and subsequently showed acinematograph film illustrating his methods of

bandaging, skin-grafting, and injecting varicoseveins.

Dr. J. H. TWISTON DAVIES said that between April,1930, and June, 1931, he had treated 98 cases of

gravitational ulcer by Mr. Wright’s method. Ofthese, 68 were healed, 11 had been referred to theirown doctors and were believed to be cured, 5 hadbeen lost sight of, and 14 were still under treatment.Four of these last would not heal. He had alwaysfound that dermatitis could be cured by a second and

1 See THE LANCET, 1931, i., 457, 474.

tighter application of Elastoplast. He had found thesame treatment successful for chronic eczema, andin Bazin’s disease.’ Dr. RUPERT HALLAM congratulated Mr. Wrighton the remarkable success of his treatment. Itwas a common error to think that a large propor-tion of ulcers of the leg were syphilitic. Of 56unseated cases of leg ulcers attending his out-

patients only five had a positive Wassermann reaction,and antisyphilitic treatment did not improve theulcers in any of these five cases.

Dr. J. T. INGRAM said he had found small multipleulcers associated with varicose veins the most difficultto heal. Dr. H. C. SEMON suggested the use of silverfoil between the ulcer and the bandage in cases

which were slow to heal. Dr. J. 0. SUMMERHAYESsaid that thin metal had been used in India for thispurpose. He called attention to the fact that elasto-

plast bandages were now allowed for panel patients.Dr. H. D. HALDIN-DAVIS had found the occurrence ofeczema the chief objection to the use of elastoplastbandages. Drs. R. SILCOCK, H. BROWN, G. B. DOwLING,and others asked questions about the details of histreatment, and Mr. WRIGHT briefly replied.

Thallium and Ringworm.Dr. INGRAM read a paper on the treatment of ring-

worm of the scalp by thallium acetate. Thalliumtreatment, he said, was first introduced in 1927.Thallium was a heavy metal, and was very toxic,especially if given in repeated doses. Of the 24 casesof death following its use, which had been reported,four had received ten times the maximum dose.In 16 cases, which had occurred in an orphanage,there was gross overdosage. In four there was no

overdosage but the method of administration was atfault, the thallium being given in repeated doses at4, 5, and 7 days respectively. His own method was,to multiply the weight of the child in lbs. by four.This gave the dose in mg. After a dose up to 200 mg.the child was seen in the ordinary routine examination.Between 200 and 250 mg. the child was kept underobservation, if possible, in bed. The dose was not

repeated under three months. As epilation was

never complete, the head was painted with 2 per cent.tincture of iodine t.d.s. and washed on alternatedays. The results had been very satisfactory ;of 101 cases thus treated 94 were entirely successful.In three cases only were there severe toxic symptoms.Dr. SEMON said he had used the treatment since

its introduction and had no cause to regret it.He completed epilation by hand at the fifteenth tosixteenth day under light anaesthesia, but he wouldnow try Dr. Ingram’s method of using 2 per cent.iodine.

Dr. HALDIN-DAVIS limited the use of thallium tothose who were too young for X rays. His methodwas to multiply the weight of the child by 3-9, buthe never gave more than 150 mg. He made a practiceof checking the dispenser’s calculations and measuresto prevent errors.

Dr. TwiSTON DAVIES endorsed everything Dr.

Ingram had said. He had reported a case in 1928of a child, aged 9 years, who was seriously ill for sixweeks after a therapeutic dose, and who still hadattacks of giddiness three months later. She hadbeen seen recently and was perfectly well.

Salvarsan Compounds.Dr. SEMON, in a paper on the Toxicology of

Salvarsan Compounds, said that the arsenical contentof salvarsan was still the generally accepted cause oftoxic manifestations ensuing during or after its

914

administration. He personally had never seen a

case of jaundice following the administration ofarsenic. Further, if it was the arsenic in the salvarsanthat damaged the liver, we ought to see an equivalentnumber of cases of neuritis, but he had never seenor heard of a case of foot-drop following an injectionof salvarsan. He thought there was even less justifica-tion in thinking that arsenic was responsible for thedermatitis which follows the use of salvarsan ** Headmitted that the case of acute dermatitis aftersalvarsan is clinically indistinguishable from that dueto inorganic arsenic, or from acute dermatitis due toany other cause. It was quite otherwise with thepigmentation which followed the prolonged administra-tion of inorganic arsenic, and which was never seenafter salvarsan. In support of these clinical conten- i

tions that arsenic is not the main cause of eithercutaneous or hepatic complications after salvarsan,Dr. Semon gave an account of certain biochemical

investigations by Drs. V. E. and N. L. Lloyd whichpoint to the amino-benzene derivatives as being thecause of salvarsan jaundice. He further pointedout that a similar type of jaundice was seen among theT.N.T. workers during the war, and has also followedanother benzene derivative, atophan. He concludedby saying that, in his opinion, the time had comefor a revision of the 1922 report of the SalvarsanCommittee of the Medical Research Council, whichattributes the toxic manifestations of salvarsan to thearsenic, and which almost ignores, or omits to examine,the evidence for other possible or more probable.causes.

REVIEWS AND NOTICES OF BOOKS

Selected Writings of John Hughlings Jackson.,

Vol. I. : On Epilepsy and Epileptiform Convulstons.Edited by JAMES TAYLOR, M.D., F.R.C.P. London :Hodder and Stoughton. 1931. Pp. 500. 25s.

IT is 20 years since Hughlings Jackson died.Justly considered the founder of scientific neurologyin England, his name has ever been one to conjurewith among those who knew him in the flesh and whofell under his personal influence. Comparativelyfew honours came his way in life ; his fame restedsecurely in the minds, as did affection for him in thehearts, of those who were fortunate enough to be ofhis time. Both at home and abroad the Jacksoniantradition is evident, and universal satisfaction mustbe felt by those who owe much to him that now atlength a collection of the works on which his ultimatereputation must depend has appeared under theable editorship of Dr. James Taylor. While manyof the papers chosen by the editor must be familiarto neurologists the world over, there are includedothers which have always been rather inaccessible,and it is gratifying to see these here reproduced. Onewho turns over these pages is brought into contactwith a philosophic mind capable in a phenomenaldegree of seeing beyond clinical data, minutelyobserved and recorded, to fundamental dynamicconceptions of neural and psychical function. Even

to-day fresh light is seen to be thrown on familiarsymptoms by the genius who could synthesise as wellas analyse, and who sought tirelessly for causes andexplanations concording with general scientific canonsand principles in other fields than the purely neuro-logical. It is surprising, perhaps, how little in thevolume would in these days be considered obsoleteif not actually mistaken, when the state of knowledgeof Jacksonian times is borne in mind. Epilepsy isunchanged in its essentials-a remark not applicableto all nervous affections ; and these Jacksoniancontributions can be studied again with great benefitby twentieth century workers.

La defense de la sante publique pendant laguerre.By Dr. LEON BERNARD, Professor of Medicine,Paris. For the Carnegie Endowment for Iiiter-national Peace. London : Humphrey Milford,Oxford University Press. 1931. Pp. 336. 8s. 6fL

Tiiis new volume. in a series dealing with theeconomic and social history of the world war, is

concerned with the problems of public health whicharose in France and among French troops as theresult of the hostilities, and with the measures

adopted to meet them. A concise account, in Part I.of the book, of the general measures taken to protectthe civil and military populations from the diseaseswhich are apt to follow in the train of war, is followedby a detailed survey of the influence of hostilities

upon the incidence, mortality, and control of the

principal acute communicable diseases. In thethird and last part, the social scourges-viz:, tuber7culosis,’ venereal disease, alcoholism, and maternaland infant mortality-are discussed at considerablelength.

Prof. Bernard directs attention to the heavyincidence of the epidemic diseases in training camps,especially in the early years of the war, as contrastedwith the armies at the front ; to the steady, and inthe case of diphtheria and epidemic meningitis, therapid decline of incidence in training camps after thefirst year; and he concludes that sub-infectionsproducing mass immunisation were the cause of thisdecline. He attributes the lesser extent to whichmeasles shared in this movement to the absenceof durable latent immunisation to this disease. As to

mumps, there was actually a heavier incidence bothin camps and at the front toward the end of the war.An interesting observation relates to the fatality ofmeasles and scarlatina, which was much higherin hospitals and camps than in the field, a circumstancewhich the author attributes to the reduced oppor.tunity for secondary infections at the front. As

regards tuberculosis, venereal diseases, and childwelfare, it is abundantly shown how the emergenciesof the war promoted measures which had beententative only in France before 1914, and how thecountry is now benefiting from the experience thenacquired. The book is full of interesting charts andtables, and is well indexed.

Demonstrations of Physical Signs in ClinicalSurgery.Third edition. By HAMILTON BAILEY, F.R.C.S.,Surgeon to the Royal Northern Hospital. Bristol:John Wright and Sons, Ltd. 1931. Pp. 227. 21s.

IN its new form some omissions from formereditions of this book have been rectified, whilst theinsistence on the names of originators of clinicalsigns has been dropped. The student passing overfrom medical school to hospital practice could not