2
497 laid aside) and the force required to produce it is great, therefore the damage is great. Had I met with bowel in an ordinary case of hernia presenting the naked-eye appearance seen in this case I should certainly have hesitated to excise it. I think the success of this case may be attributed to the early period at which the operation was performed and the excision of the bowel left no potential cause of mischief behind. In spite of the severance of Poupart’s ligament there has so far been no evidence of a hernia there. Medical Societies. PATHOLOGICAL SOCIETY OF LONDON. Blood Glands as Pathogenic Factors in the Production of Diabetes and Obesity.-Leucocythæmia with Change of Type from Spleno-medullary to Lyniphatic. A MEETING of this society was held on Feb. 21st, Mr R. J. GODLEE being in the chair. Dr. ARNOLD LORAND made a communication on Blood Glands as Pathogenic Factors in the Production of Diabetes and Obesity. Dr. Lorand laid stress on the important influence exerted by the internal secretion of the blood glands on all the vital processes of the body and pointed out that the influence of the thyroid, the sexual glands, and the hypophysis was in the direction of increasing oxidation. Inefficiency of these organs led to a diminution of oxidation. All blood glands stood in close relation to one another, pathological changes in one being followed by alterations in others. Extirpation of the pancreas in four dogs was followed by enlargement of vesicles and considerable increase in the colloid substance of the thyroid. The effects of increased colloid secretion were seen in cases of exophthalmic goitre in which the symptoms resembled those produced by the administration of large quantities of thyroid tablets. This condition of thyroidism, especially when it was associated with pathological changes in the pancreas, was likely to produce toxic decomposition of proteids and resulting glycosuria. The internal secretion of the pancreas was probably produced by the Langerhans islets which presented similarities in their structure to that of the parathyroids, the medullary part of the adrenals, and the interstitial cells of the testicles. The secretion of these islets was probably under the influence of a nervous mechanism and it was necessary to take this into account in explaining those cases of diabetes in which no pathological changes were found in the gland after death. Degeneration of the pancreas had been described in cases of Graves’s disease and acromegaly associated with diabetes. Glycosuria was comparatively frequent in exophthalmic goitre but was unknown in connexion with myxcedema and in the latter condition could not even be produced by the ingestion of large quantities of grape sugar. Extirpation of the thyroid was followed by increase in the number, and perhaps new formation, of the islets of Langerhans in the head of the pan- creas. Moreover, the glycosuria had disappeared in the case of three diabetic dogs from which the thyroid gland had been removed. In all states of hyperthyroidia, whether due to infectious diseases, mental shock, or other causes, there was not only frequently glycosuria but also loss of weight. On the other hand, in athyroidia obesity was frequent. Extirpation of the sexual glands led to similar results with regard to obesity and it was noticeable that the formation of fat was common as a sequel to frequent preg- nancies and prolonged lactation. After the menopause the thyroid and the hypophysis showed interstitial changes with fatty degeneration of the epithelial structures. Moussu, Babes, and others had shown that after extirpation of the thyroid and the ovaries breast milk was very rich in fat and very poor in sugar. Obesity had been associated with tumours of the hypophysis even in the absence of symptoms of acromegaly. The cases of obesity caused by degenerative changes in the blood glands-endogenous obesity-were clinically different from those caused by over-feeding- exogenous obesity. Glycosuria was rare in the former but frequent in the latter class. If the pancreas only was degenerated, as was sometimes the case in old people with arterio-sclerosis, the glycosuria was slight, but if the pancreatic change was combined with very active thyroid secretion, as in young persons, the glycosuria was likely to be severe. In 20 cases of diabetes the serum of sheep which had undergone thyroidectomy had given good results. In the treatment of obesity in women ovarian extracts should be used as well as thyroid gland.- Dr. F. W. PAVY referred to the question of the occurrence of diabetes in association with myxocdema and although he could not remember having met with such a combination in his own experience cited the reports of three cases in children which he had found in the Journal of the Phila- delphian Medical Society. His own experiments tended to show that the internal secretion of the pancreas promoted the assimilation of carbohydrates and that sugar passed through the circulation in a combined form in healthy animals.-Dr. H. BATTY SHAW suggested that it was possible for myxeedema and exophthalmic goitre to occur together in the same patient.-Dr. LORAND replied. Dr. C. H. MELLAND reported a case of Leucocythæmia with change of type from the spleno-medullary to the lym- phatic. A woman, aged 35 years, came under observation in June, 1904. The symptoms of general weakness dated from Christmas, 1903, and about two months later a swelling had been noticed in the abdomen. On examination the spleen was found to occupy the whole of the left side of the abdomen but there was no evidence of enlargement of lymphatic glands. The most noticeable feature in the examination of the blood was the large increase in the number of large lymphocytes which at first were as numerous as 46 per cent., and later as 83 per cent., of all the white cells. In six other cases he had found the average to be about 14 per cent. The myelocytes formed at first 22 per cent. and later 4 per cent. of the leucocytes. In spite of treatment the patient died on Sept. 17th. Post mortem the spleen weighed 26 ounces, the liver showed small aggrega- tions of white cells, and the lymphatic glands no enlargement or evidence of hyperactivity. The bone marrow contained very few eosinophilic or neutrophilic myelocytes and con- sisted almost entirely of non-granular cells similar to the large lymphocytes of the blood. Dr. Melland had come to the conclusion that the large lymphocytes really represented myelocytes which had undergone retrograde changes and he had been able to trace all gradations from large cells with no true granules, but with a certain amount of basophilic stippling, up to the typical neutrophilic myelocyte. He was inclined to regard his case, therefore, as a pure but acute spleno-medullary leucocythsemia. and not one in which the spleno-medullary and lymphatic types were mixed.-Mr. L. S. DUDGEON referred to the important part played by the hæmolymph glands as well as the bone marrow in these cases and said that he had sometimes found the thymus much enlarged. He preferred the terms myelæmia and lympho- cythæmia to those used by Dr. Melland and emphasised the difference in the blood conditions found in the two varieties. - Dr. F. PARKES WEBER referred to another case of acute leukaemia which he was about to publish and which tended to confirm Dr. Melland’s views with regard to the deriva- tion of the large non-granular cells in the blood. In the terminal stages the white cell count fell to 3000 per cubic millimetre and all these presented the characters of large lymphocytes.-Dr. R. HUTCHISON asked whether Dr. Melland had formed an opinion as to the possible origina- tion of the smaller lymphocytes from the same source as the myelocytes and expressed the opinion that the case reported confirmed the fact that the frontiers between the different forms of leucocythæmia were very ill defined.-Dr. H. BATTY SHAW agreed with Dr. Melland and the latter replied. LIVERPOOL MEDICAL INSTITUTION. Modified Eye Speculum. Internal Hydrocephalus. Addison’s Disease.- Union of Divided Nerves. , A MEETING of this society was held on Feb. 16th, Dr. JAMES BARR, the President, being in the chair. Mr. RICHARD WILLIAMS exhibited and demonstrated the particular advantages of a Modified Eye Speculum. Dr. T. R. GLYNN and Dr. E. E. GLYNN brought forward a case of Internal Hydrocephalus in which the symptoms simulated those of intracranial tumour. The patient received a blow on the head in 1898 which caused temporary loss of consciousness. Gradually symptoms of cerebral tumour developed and these symptoms continued until H 3

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497

laid aside) and the force required to produce it is great,therefore the damage is great. Had I met with bowel in an

ordinary case of hernia presenting the naked-eye appearanceseen in this case I should certainly have hesitated to exciseit. I think the success of this case may be attributed tothe early period at which the operation was performed andthe excision of the bowel left no potential cause of mischiefbehind. In spite of the severance of Poupart’s ligamentthere has so far been no evidence of a hernia there.

Medical Societies.PATHOLOGICAL SOCIETY OF LONDON.

Blood Glands as Pathogenic Factors in the Production of .

Diabetes and Obesity.-Leucocythæmia with Change ofType from Spleno-medullary to Lyniphatic.A MEETING of this society was held on Feb. 21st, Mr

R. J. GODLEE being in the chair.Dr. ARNOLD LORAND made a communication on Blood

Glands as Pathogenic Factors in the Production of Diabetesand Obesity. Dr. Lorand laid stress on the importantinfluence exerted by the internal secretion of the bloodglands on all the vital processes of the body and pointedout that the influence of the thyroid, the sexual glands,and the hypophysis was in the direction of increasingoxidation. Inefficiency of these organs led to a diminutionof oxidation. All blood glands stood in close relation toone another, pathological changes in one being followedby alterations in others. Extirpation of the pancreasin four dogs was followed by enlargement of vesiclesand considerable increase in the colloid substance of the

thyroid. The effects of increased colloid secretion were seenin cases of exophthalmic goitre in which the symptomsresembled those produced by the administration of largequantities of thyroid tablets. This condition of thyroidism,especially when it was associated with pathological changesin the pancreas, was likely to produce toxic decomposition ofproteids and resulting glycosuria. The internal secretion ofthe pancreas was probably produced by the Langerhans isletswhich presented similarities in their structure to that of theparathyroids, the medullary part of the adrenals, and theinterstitial cells of the testicles. The secretion of theseislets was probably under the influence of a nervous

mechanism and it was necessary to take this into account in

explaining those cases of diabetes in which no pathologicalchanges were found in the gland after death. Degenerationof the pancreas had been described in cases of Graves’sdisease and acromegaly associated with diabetes. Glycosuriawas comparatively frequent in exophthalmic goitre but wasunknown in connexion with myxcedema and in the lattercondition could not even be produced by the ingestion oflarge quantities of grape sugar. Extirpation of the thyroidwas followed by increase in the number, and perhaps newformation, of the islets of Langerhans in the head of the pan-creas. Moreover, the glycosuria had disappeared in the caseof three diabetic dogs from which the thyroid gland had beenremoved. In all states of hyperthyroidia, whether due toinfectious diseases, mental shock, or other causes, therewas not only frequently glycosuria but also loss of weight.On the other hand, in athyroidia obesity was frequent.Extirpation of the sexual glands led to similar resultswith regard to obesity and it was noticeable that theformation of fat was common as a sequel to frequent preg-nancies and prolonged lactation. After the menopausethe thyroid and the hypophysis showed interstitial changeswith fatty degeneration of the epithelial structures. Moussu,Babes, and others had shown that after extirpation of thethyroid and the ovaries breast milk was very rich in fatand very poor in sugar. Obesity had been associated withtumours of the hypophysis even in the absence of symptomsof acromegaly. The cases of obesity caused by degenerativechanges in the blood glands-endogenous obesity-wereclinically different from those caused by over-feeding-exogenous obesity. Glycosuria was rare in the former butfrequent in the latter class. If the pancreas only wasdegenerated, as was sometimes the case in old people witharterio-sclerosis, the glycosuria was slight, but if thepancreatic change was combined with very active thyroid

secretion, as in young persons, the glycosuria was likelyto be severe. In 20 cases of diabetes the serum of

sheep which had undergone thyroidectomy had givengood results. In the treatment of obesity in womenovarian extracts should be used as well as thyroid gland.-Dr. F. W. PAVY referred to the question of the occurrence ofdiabetes in association with myxocdema and although hecould not remember having met with such a combination inhis own experience cited the reports of three cases inchildren which he had found in the Journal of the Phila-

delphian Medical Society. His own experiments tended toshow that the internal secretion of the pancreas promotedthe assimilation of carbohydrates and that sugar passedthrough the circulation in a combined form in healthyanimals.-Dr. H. BATTY SHAW suggested that it was possiblefor myxeedema and exophthalmic goitre to occur together inthe same patient.-Dr. LORAND replied.

Dr. C. H. MELLAND reported a case of Leucocythæmiawith change of type from the spleno-medullary to the lym-phatic. A woman, aged 35 years, came under observationin June, 1904. The symptoms of general weakness datedfrom Christmas, 1903, and about two months later a swellinghad been noticed in the abdomen. On examination thespleen was found to occupy the whole of the left side of theabdomen but there was no evidence of enlargement oflymphatic glands. The most noticeable feature in theexamination of the blood was the large increase in thenumber of large lymphocytes which at first were as numerousas 46 per cent., and later as 83 per cent., of all the whitecells. In six other cases he had found the average to beabout 14 per cent. The myelocytes formed at first 22 percent. and later 4 per cent. of the leucocytes. In spite oftreatment the patient died on Sept. 17th. Post mortem the

spleen weighed 26 ounces, the liver showed small aggrega-tions of white cells, and the lymphatic glands no enlargementor evidence of hyperactivity. The bone marrow containedvery few eosinophilic or neutrophilic myelocytes and con-sisted almost entirely of non-granular cells similar to the

large lymphocytes of the blood. Dr. Melland had come tothe conclusion that the large lymphocytes really representedmyelocytes which had undergone retrograde changes and hehad been able to trace all gradations from large cells with notrue granules, but with a certain amount of basophilicstippling, up to the typical neutrophilic myelocyte. He wasinclined to regard his case, therefore, as a pure but acutespleno-medullary leucocythsemia. and not one in which thespleno-medullary and lymphatic types were mixed.-Mr.L. S. DUDGEON referred to the important part played by thehæmolymph glands as well as the bone marrow in thesecases and said that he had sometimes found the thymus muchenlarged. He preferred the terms myelæmia and lympho-cythæmia to those used by Dr. Melland and emphasised thedifference in the blood conditions found in the two varieties.- Dr. F. PARKES WEBER referred to another case of acuteleukaemia which he was about to publish and which tendedto confirm Dr. Melland’s views with regard to the deriva-tion of the large non-granular cells in the blood. In theterminal stages the white cell count fell to 3000 per cubicmillimetre and all these presented the characters of largelymphocytes.-Dr. R. HUTCHISON asked whether Dr.Melland had formed an opinion as to the possible origina-tion of the smaller lymphocytes from the same source as themyelocytes and expressed the opinion that the case reportedconfirmed the fact that the frontiers between the differentforms of leucocythæmia were very ill defined.-Dr. H. BATTYSHAW agreed with Dr. Melland and the latter replied.

LIVERPOOL MEDICAL INSTITUTION.

Modified Eye Speculum. - Internal Hydrocephalus. -Addison’s Disease.- Union of Divided Nerves.

, A MEETING of this society was held on Feb. 16th, Dr.JAMES BARR, the President, being in the chair.

Mr. RICHARD WILLIAMS exhibited and demonstrated theparticular advantages of a Modified Eye Speculum.

Dr. T. R. GLYNN and Dr. E. E. GLYNN brought forwarda case of Internal Hydrocephalus in which the symptomssimulated those of intracranial tumour. The patientreceived a blow on the head in 1898 which caused temporaryloss of consciousness. Gradually symptoms of cerebraltumour developed and these symptoms continued until

H 3

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498

June, 1903, when clear fluid commenced to flow from theright nostril and very soon improvement set in, followed bycomplete recovery in tl.e course of a few weeks.-Mr. F. C.LARKIN, Dr. R. CATON, Dr. W. B. WARRINGTON, Dr. F. A.GILL, Dr. R. J. M. BUCHANAN, Dr. J. HILL ABRAM, and Mr.W. THELWALL THOMAS discussed the case.

Dr. A. G. GULL AN read notes of two cases of Addison’sDisease in which he had administered Suprarenal Extract.In the first case, that of a young man, in whom the symptomsof the disease were well marked, 15 grains of the extractwere given thrice daily but with only temporary relief, thepatient dying seven weeks later. At the post-mortem exa-mination no signs of tubercle were found except in the supra-renal bodies which were both enlarged and destroyed bycaseous masses evidently of a tuberculous nature. In thesecond case, that of a woman, the symptoms were less severeand she had benefited greatly by taking 20 grains of theextract thrice daily.

Mr. DAMER HARRISSON opened a discussion on the Unionof Nerves after Division He gave a short history of thesubject, physiological and surgical. The more recent

histological observations which support the theory ofcoalescence and the process of regeneration in the peri-pheral end of a divided nerve were described, together withthe criticisms of Mott, Halliburton, and Edmunds. On the

physiological side he advanced the view that the weight ofevidence was on the side of the outgrowth theory andbrought forward a series of observations made by himselfand Professor F. Gotch after division and suture of thesciatic nerve in the rabbit which proved that sensationreflexes appeared first in the peripheral end nearest the pointof suture and at later periods at the more distant points inthe peripheral end. With regard to the motor response thisappeared at an earlier date in proportion to the nearness ofthe division and suture to the muscles. These facts weredifficult to explain by means of the coalescence theory andstrongly supported the outgrowth theory.-Dr. ROBERTKENNEDY said that from the clinical point of viewthere was a well-established observation which thecentral theory of regeneration of nerves could not

explain-namely, the early return of sensation after

secondary suture of a divided nerve. Ranvier’s view didnot explain this rapid restoration, for, in the first place, un-naturally rapid growth of new nerve fibres from the centralend would be required, as no sensation could be felt untilthe axis cylinders had reached the end organs. In thesecond place, there would be a difference of time in the re-appearance of sensation accordingly as the section of thenerve was near or far removed from the end organs, whichthere was not. As regards suture of the nerve immediatelyafter section, sensation took much longer to appear, andthis was what would be expected, as time was required forregeneration of the new fibres in the distal segment. Whensuture was performed at a time remote from section the distalsegment had had time to form its new nerve fibres. The onlydifficulty was to explain the very early passage of impulsesacross the plane of suture, but this was probably broughtabout by the junction of neurilemma cells newly formedfrom the central and peripheral ends, the gap being thusbridged, the impulses apparently having the power to passalong the protoplasm of such cells. The reason why motionrecovered later than sensation was owing to the rapid degene-ration of the muscles after nerve section, which degene-ration must first be recovered from. From observationsmade in the past few years Dr. Kennedy was of opinionthat muscular tissue never completely degenerated, althoughseparated from the nerve centres for long periods. Aseries of microphotographs were shown illustrating hisviews of nerve regeneration in the distal segment as

opposed to the recent explanation advanced by Langleyand Anderson.-Professor C. S. SHERRINGTON said thathe favoured the peripheral rather than the central

theory of nerve regeneration and remarked that afterremoval of a spinal ganglion delicate nerve fibres could befound in the portion of the root attached to the cord.-Dr.W. B. WARRINGTON called attention to certain alterations inthe nerve cell which took place after section of its axone.In this condition, known as chromatolysis, the cells assumedthe embryological form in preparation for renewed activity.Chromatolysis occurred in nearly all the cells of the

spinal ganglia when the section was made on the peripheralside but not at all when the posterior root was divided.In the former case the nerve fibres regenerated but not inthe latter. Similarly, af:t’r section of the anterior root

nearly all the cells of the corresponding segment in the verte-bral horn underwent chromatolysis and ultimately repaired,but after cutting off the incoming impulses by division ofthe posterior roots and thus producing a permanent isolation,some of the cells of the anterior horn atrophied and under-went complete degeneration. It was submitted that theseexperiments furnished evidence of the important part takenby the cell in the regeneration of a nerve fibre.-Mr. J. S.MACDONALD and the PRESIDENT also took part in thediscussion.

EDINBURGH MEDICO-CHIRURGICALSOCIETY.

Recurring Torsion of the Spermatic Cord.-Massage inCardiac Dilatation.-Bradycardia.

A MEETING of thi’- society was held on Feb. lst, ProfessorJOHN CRIENE, the President, being in the chair.

Mr. J. W. DOWDEN read a paper on Recurring Torsion ofthe Spermatic Cord. It was based on five cases which hadcome under Mr. Dowden’s own observation and on five otherrecorded cases. The varieties of this affection had beenclassified by Perry as (1) acute, where there was one suddenand severe attack; and (2) "recurring," where the attackswere more or less frequent with or without the eventual onsetof an acute attack. The main predisposing factor was themanner in which the testicle, epididymis, and part of thecord were covered entirely by visceral tunica vaginalis and sohung free in the serous sac, giving rise to a condition of"floating testicle." There was also a broad arrangement ofthe cord with its constituents grouped in two parts, thevas deferens at one free border and passing to the globusminor, while the main vascular structures at the other freeborder passed to the globus major (" intermesorchial separa-tion of the cord "). Puberty was a predisposing factor, as itwas also in acute torsion. In six out of the ten cases thetesticle was a descended one. Both sides were equally affected.The patients gave a history of attacks from time to time ofsudden pain in the testicle associated with collapse, vomiting,and great local tenderness with (in a few hours) swelling ofthe testicle. Sudden relief of the severe symptoms occurredwith the disappearance of the swelling in about 24 hours.Such attacks might go on for years. The condition could bedistinguished from epididymo-orchitis by the suddenness ofthe onset and the severity of the collapse. After swellinghad occurred in the scrotum a strangulated hernia might besimulated but pain followed in some hours by swelling wasthe main distinctive sign of torsion. A case of an infant,aged five months, and another of a child, aged three years,showed that recurring torsion might happen in infancy.The direction of the twist was ascertained in eight cases andin seven it was from without inwards and the twist variedfrom half a turn to two turns. The treatment in an attackwas to perform detorsion and if this failed an immediateoperation to untwist and to fix the testicle was required. Inthe interval fixation of the testicle should be carried out byclipping away the parietal tunica vaginalis and suturing thetesticle to the scrotum.-Mr. DAVID WALLACE and Mr.ALEXANDER MILES took part in the discussion.

Dr. R. A. FLEMING read a paper on Massage, PassiveMovements, and Modified Resisted Exercises in the Treatmentof Advanced Cardiac Dilatation, in which rest and cardiactonics had failed to yield further benefit. He thought thatthe exercises gave tone to the heart where it was possible forthe myocardium to respond at all and they probably did soby dilating the vessels and relieving the over-burdened heart.Careful percussion of the cardiac right and left borders,taken along with the position of the apex beat, yieldedaccurate data as to the contraction of a dilated heart. Themethod of treatment consisted in successive periods of dailymassage, followed from seven to ten days later by passivemovements of the arms and legs and after other seven toten days by resisted exercises. The patient was notallowed out of bed during the period of from 21 to30 days and the exercises were limited, therefore, tothose which could be performed in bed. Clinical de-tails were given of ten cases, two of which were cases

of aortic and mitral incompetence and in neither ofthese two was the treatment successful. In the remainingeight cases success followed the treatment, the patients wereallowed up after the period of resisted exercises was finishedand were made to walk slowly for a few minutes, and theperiod of active exercise thus taken was gradually lengthened