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constantly found, is present from the second dayof the disease, and may persist after the swellingof the parotids has subsided. I have examined about60 cases, making diastase estimations at varyingperiods in the course of the illness. The diastasewas estimated in Wohlgemuth units, but the techniquewas adapted to avoid geometrical progressions in thedilutions in order to get as near as possible to theatual excretion rate. The urines were all adjustedto the optimum pH, but no measures were takento secure a uniform excretion rate of water. Thefailure to secure uniformity in this respect no doubtaccounts for the variation found in the number ofunits of diastase in different samples of urine fromindividual cases, but in spite of this all the readingswere well above 30 units per c.cm., some being over 200.
The question naturally arises : Whence is this
surplus diastase derived, and does pancreatitis occurmore frequently in mumps than is commonly sup-posed ? I tested 21 of these cases by Loewi’s methodof instillation of 1/1000 adrenaline solution into theconjunctival sac, with completely negative results.The faeces were not tested for pancreatic activity ;but if reliance can be placed on the adrenaline test,then the diastase in all probability is derived from theparotids.
Since making use of this test, I have made it a rulethat no case of mumps shall be allowed to mix withothers until the urinary diastase has returned to
normal, which may be some days after the swellinghas subsided ; and I believe that this helps con-
siderably in shortening epidemics.
THrs congress met at Oxford from July 5th to7th under the presidency of Mr. CYRIL H. WALKER(Bristol), the Master. Among the contributions wasone initiating a symposium on the
Treatment of Glaucoma
by Dr. S. HoLTH (Oslo). The first successful operationfor this condition was performed, he said, in 1857,when local anaesthetics were unknown. He spoke ofiridectomies before and after the use of cocaine, withmiotics, the tonometer, and filtering scars. Heremarked that he had now completely abandonedclassical iridectomy, replacing it by iridencleisis.
Mr. G. YOUNG (Colchester) appeared as a strongadvocate of non-operative treatment of glaucoma.Leaving out of consideration exceptional cases, suchas low-tension glaucoma, or hospital patients who camefrom a long distance and returned, so that super-vision was impossible, the action of pilocarpine shouldbe tested, with the aid of the tonometer. His
experience was that the cases which responded did sopermanently if periodically controlled, if the strengthand frequency were regulated, and if the patient wascompletely obedient. Much could be said in favourof leaving well alone when there seemed sound reasonfor believing that conservative treatment wouldkeep blindness at bay.
Lieut.-Colonel R. E. WRIGHT, I.M.S., said thatmost of the cases of glaucoma met with in hospitalpractice in Madras were of the chronic primaryvariety, chiefly the non-congestive type, with
markedly high tension, advanced field changes, anddiminished visual acuity. In this group, if any visionremained, the patient was admitted with a view tooperation, but a prior course of preparation wasundertaken to reduce the tension, so that operationcould be done when the tension was at the lowest
possible. At the due time, instillations of per cent.solution of eserine were carried out at frequentintervals, leeches were applied on the affected side,a purge was given, and rest at night ensured. Iftension tended to come down, the eserine was
continued next day, but at longer intervals, massagealso being practised. If the eye did not respond toseveral days of this, an adrenaline pack was given.This was found to cause an initial rise in tension forsome hours, followed by a slow fall, which reached itslowest point on the third day. Usually this fall wasnot maintained more than a week, and then a rise
set in, in spite of the routine eserine and massagetreatment. Frequent instillations of eserine beforeand after the pack tended to diminish the initial rise.If the tension failed to come below 25 mm. Bailliart,Colonel Wright preferred to do an anterior sclerotomywith a Herbert’s knife, and watched with operatinglenses the effect on the iris vessels. If there wasmarked engorgement or a trace of oozing, nothingfurther was done at the time, and non-operativemeasures and repeated paracentesis were instituted.In some cases in which tension had come down tonormal after non-operative treatment he had recentlybeen trying cyclodialysis, and the results of this wereastonishingly good ; it seemed to be a useful, simple,and effective procedure in some of the chronic hightension cases, and it might be a safer operation thandecompression in cases responding badly to non-
operative treatment.From the standpoint of treatment a second group
were those of well-defined glaucoma simplex, alsocases of primary glaucoma, both congestive and
non-congestive, moderate in degree, in which thetension was not permanently high, but yet was neverquite normal and in which there might be markedfield changes, but little or no visual disturbance. Insuch well-marked cases careful field-taking was
necessary, and tonometric observations were made,the ultimate aim being decompression. His experienceof iridencleisis was that in order to obtain good resultsthe patient must be kept under non-operative treat-ment for a variable time, always under observation.A third group of cases were those of early chronicprimary glaucoma and glaucoma simplex, and when thiscondition was diagnosed it was for the surgeon to decidewhether operation was called for. In hospital patientswhose means did not permit of prolonged observationand non-operative treatment, decompression was
advised. He did not feel so sure as some ophthalmicsurgeons did that sclero-corneal trephining was the oneand only effective operative treatment for all cases ofchronic glaucoma, and- h was inclined to employiridencleisis more extensively, especially where thereseemed reason to fear the effects of a great, sudden,and prolonged fall in the tension. Yet his impressionwas that sclero-corneal trephining, when well per-formed in suitable cases, was the surest form ofdecompression and best adapted to the hospitalpatient.
Acute congestive primary glaucoma was notcommon in his hospital practice. Usually for thesecases the methods already mentioned were pushed,with the exception of the adrenaline pack. If thetension did not respond at once, one could employ
the intravenous injection of a 30 per cent. hypertonicsolution of sodium chloride as described by Duke-Elder ; but it was a slow and difficult process, andsevere on the patient. In the acute secondaryglaucomas of endocular inflammation, he and his
colleagues, in India, depended a good deal on
paracentesis if the tension was dangerously high,because of the local mydriatic treatment, or in spite ofmiosis. In chronic secondary glaucoma the cause ofthe disease was thoroughly treated. If the inflam-
matory process had subsided he did a broadiridectomy, having previously injected calciumchloride and horse serum. In absolute glaucoma ifthe eye was painful and blind it might be dealt withby opticociliary neurectomy or alcoholic block if itwas desirable to retain it, but one must make surethere was no intra-ocular tumour.
Mr. J. BURDON-COOPER (Bath) said that no caseof glaucoma should be operated upon until everyeffort had been made to quieten the eye by means ofsome form of conservative treatment. Morphiasoothed the nervous system, causing sleep, whichwas a natural cure for glaucoma, and the contractionof the pupil intensified the effect of eserine.
Mr. T. HARRISON BUTLER (Birmingham) said thatafter iridencleisis had been done the patient might beable to leave the hospital within a week, whereas thereaction after trephining was probably the mostsevere of any operation on the eye. During trephiningthe patient usually suffered a little pang of acute
pain, but there was little suffering accompanyingiridencleisis. After trephining the eye was nearlyalways red and congested for a few days ; it was
exceptional for the latter to be seen after iridencleisis.Mr. MALCOLM HEPBURN (London) remarked that if
ophthalmic surgeons could be sure that non-operativemethods were able to produce benefit such methodsought to be more frequently employed. His own
experience had led him to conclude that when, fromany cause, the tension was high, and could not belowered by non-operative measures, an operation wasneeded.Mr. ALEXANDER MACRAE (Newcastle-on-Tyne),
speaking of late infection, said he had operated upon90 eyes, and among them were three cases of lateinfection. In two of the cases the patients came atonce under suitable energetic treatment, and the eyeswere still visually useful. The third patient went solong without care that the eye was hopeless by thetime she was seen. He thought it was useless to baseany statistics on the results of operations after a fewweeks, but if the cases were taken in which trephininghad been done years before, the proportion in whichtension rose after operation was high, the number inwhich tension had remained low for years being verysmall.
Necrotic Sarcoma of the Uvea
Dr. BERNARD SAMUELS (New York), who read apaper on 85 cases of this condition, said that bothsarcoma and glioma showed necrosis and degenerativechanges, like other tumours of the body, but thoughglioma underwent early and very marked necrosisthere was little local reaction, while in sarcoma
necrosis began later, was not so extensive, and theinflammatory reaction was very marked. Glioma,therefore, was not so toxic as was sarcoma. Insarcoma the diagnosis was easiest in the first stage,because of the great dilatation of the blood-vesselsin the choroid. The bright red rims surrounding flatsarcoma was most marked on the side next to theoptic nerve, due to disturbance in the circulation.With the growth of the tumour the circulation became
so disturbed that a transudation of fluid occurred,and that produced detachment of the retina, thislatter rendering the diagnosis more difficult. In thesecond stage the tumour simply grew through a smallopening in the lamina vitrea, and a globule was formed,and in the third stage the tumour made its wayoutside in the eyeball. The fourth stage was one ofmetastasis, though this could occur at any stage.If there was a scleritis interna the patient had pain.The most difficult cases to diagnose were those inwhich the tumour was round the optic nerve, becausethere was an enormous detachment of the retina, andthe tumours were so posterior that they could not betransilluminated. Usually the surgeon felt it was
necessary to remove as much of the optic nerve aspossible, but it was rarely necessary, for it was seldomthat the tumour got into the optic nerve.
Mr. E. B. ALABASTER and Mr. W. STIRK ADAMS(both of Birmingham) contributed papers on
The Ears in Miners’ NystagmusMr. Alabaster remarked that the posture adoptedby the miner in his work had been held to influencethe degree of the labyrinthine responses, andin a report on the subject by the Medical ResearchCouncil it was said that miners’ nystagmus variesdirectly with the amount of labyrinthine disturbanceand inversely with the intensity of the illuminationpresent. Yet the labyrinthine condition had neveryet found general favour as an setiological factor.Mr. Sydney Scott had reported a series of 40 cases ofthe disease in which the nystagmus was unlike thatusually found, as the to and fro movements were
equal in speed, instead of one movement being slowand the other a jerk. The most persistent symptomof miners’ nystagmus was giddiness which was
brought on by movement, and it persisted when theeyes were closed. Patients frequently said theynever went out at night for fear neighbours might saythey were drunk. The ears of miners might beaffected by changes of pressure as much as those ofmen in the Air Force, and certainly deafness wasvery common among miners. Of 14 men examined,11 had definite reduction of hearing acuity, and theremaining 3, tested more minutely, were found tohave abnormal labyrinthine responses. The sequenceof events seemed to be : a catarrhal condition in thenose ; extension of infection along the Eustachiantube ; a congestive condition of the middle ear ;confusion arising from an antagonism between thetwo labyrinths ; an attempt to obtain cerebral
adaptation by means of vision ; frustration of thisattempt by the poor illumination ; fatigue of theelevator muscles; then nystagmus. A related factwas that a pigeon, both of whose labyrinths had beendestroyed, could no longer feed itself if corn was
strewn on the ground, it could only do so when thefood was placed in a container. He hoped thatotologists would have greater facilities than in thepast for studying these cases.
Mr. Adams spoke of a descent of a deepcolliery which he made with Mr. Alabaster, whenthey saw and examined 14 men, chiefly in respectof their auditory powers ; 12 of the 14 had a definitelesion of hearing. One was quite deaf for ordinarypurposes, and was proved to have mixed deafness-i.e., of both middle ear and perception character.Two of the men, however, had normal hearing, andtherefore they were crucial cases from the point ofview of this inquiry. On testing them by the galvanicand the cold caloric tests they did not give the normalresponses ; if they had done so he would have regardedthis line of inquiry as at an end. The Eustachian
tube was an important structure in this connexion,and the question arose as to whether deafness was apart of the problem. He did not think it could beexcluded.
Mr. SYDNEY SCOTT (London), though he had notseen a case of miners’ nystagmus, felt that this lineof research was likely to be fruitful, and that a
cooperation between otology and ophthalmologyshould result in a means of prevention and successfultreatment of this distressing malady. It was to theophthalmic surgeon one must look ’for the materialfor the research. He made a plea for exactitude ofterminology. He remarked also on the minute
anatomy of the semicircular canals.Mr. J. R. FOSTER (West Hartlepool) remarked on
the great variability of the hearing power in cases ofnystagmus, and said it would be valuable to be toldwhat were to be regarded as normal labyrinthine tests.Something depended, too, on the thickness of theskull bones generally, including the labyrinth walls ;in one man with a very thick skull the response tothe cold caloric test was only tardily commenced.
Mr. HARRISON BUTLER commented on the absenceof controls in this inquiry, though he was glad to seethat this aspect of the question was being tackled.There might be some subtle poison at work in thesecases of miners’ nystagmus.
, In reply Mr. ADAMS said that the central cerebralmechanism was important, and Mr. ALABASTERremarked that he could not understand why giddinessshould be so pronounced on stooping in patients withminers’ nystagmus unless the labyrinth was at fault.
NATIONAL ASSOCIATION FOR THEPREVENTION OF TUBERCULOSIS
THE nineteenth annual conference of this associa-tion was held at Cardiff from July 13th to 15th, themain subject for discussion being the part playedin the production of tuberculosis respectively by,(1) infection and (2) environmental conditions.
Introductory AddressIn his introductory address the president, Sir
ROBERT PHILIP, pointed out that the developmentof tuberculosis predicated not only the presence ofthe infecting bacillus, but also the existence ofcertain conditions favourable to its germination.Given those factors, the spread of the disease withinthe system would follow. The laboratory animalcommonly developed tuberculosis after inoculationbecause of the relatively large dose administered,although even then the course of the disease thusartificially produced might be varied by varyingexternal conditions. In the human subject thecourse of events was more complex, depending onthe widely varying dosage and the equally widelyvarying resistance offered by different individualsand by the same individual at different periods. Thevariations in the soil on which the bacillus had beenimplanted were themselves largely influenced byenvironmental conditions. The speaker had longheld that one of the primary functions of the familyphysician should be to determine carefully-by theapplication at successive intervals of one or otherof the tests that were now available-the earliestevidence of infection. It was, however, equallyimportant to study with minute care the environ-mental conditions to which the individual was, ormight be, subjected. The contributory causal factors
in tuberculosis included all influences which, howeverthey might be brought into play, tended to handicapthe individual in his struggle against the invadingbacillus. The circumstances which favoured invasion
by the tubercle bacillus were extremely complex, andthe purpose of the discussion was to get hold of themand as far as possible assess their several values andrelationships.Lord DAVIES, president of the Welsh National
Memorial Association, followed with an address onthe history and organisation of the association,pointing out that the scheme was a comprehensiveone, and one which endeavoured to lay stress uponthe preventive no less than upon the curative sideof the work. It served a unit of about two and ahalf million people, so that the staff of the associationwas able to concentrate the results obtained over aconsiderable area, and to provide adequate meansfor investigation in the institutions under theircontrol.
Prof. S. LYLE CUMMINS, occupying the chair oftuberculosis in the University of Wales, dealt withthe place of a tuberculosis department in the lifeof a medical school, showing how it linked up withresearch and undergraduate and post-graduateteaching.
Dr. D. A. POwELL, principal medical officer ofthe association, described in more detail the workingof the King Edward VII. Welsh National Memorialassociation. He said there were many advantagesin a national scheme such as this. It was adminis-tratively very convenient, it was undoubtedlyeconomical, it fostered team work and team investi-gations-in which connexion might be mentionedthe Memorial Association’s inquiry into the incidenceof silicosis amongst coal workers-and it pooled thefinancial resources of the contributing authorities.It combined, moreover, the advantages natural to avoluntary organisation with those inseparable froma State- and rate aided service. It might be claimedthat its appeal was even wider-that it had uniteda nation in a campaign against a disease to whichshe was peculiarly vulnerable and which had alwaystaken the heaviest toll of her children.
The Part Played by InfectionDr. RALPH M. PICKEN, medical officer of health
for Cardiff, said that if it was accepted that directinfection from person to person was the principalfactor in the causation not only of respiratory tuber-culosis but also of other forms of the disease acquiredvia the respiratory route, it was evident that it wasnot only the main cause of death and disablementfrom tuberculosis, but also the essential factor in thecontinuance of the disease, since it constantly pro-pagated new centres of infection. Although the
recognisable case of tuberculosis, against the riskfrom whom their ad-hoc schemes were directed, wasclearly in himself a greater danger than the unrecog-nised, and there was some evidence that the declineof the recorded incidence of pulmonary tuberculosisduring the past 15 years was the result of the increas-ing completeness and efficiency of those schemes inprocuring the early detection and detention ofinfected persons, and the segregation in hospitalsof the incurable and rapidly progressive cases, therewas, he thought, some ground for believing thatundetected carriers of infection were numerous, thatthey might be increasing in number, that there wasnot likely to be much advance in methods of ascer-taining them, and that, even if they were found, theproblem of rendering them harmless presented almostinsuperable social and administrative difficulties.