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MEDICAL SOCIETIES

ROYAL SOCIETY OF MEDICINE.

SECTION OF EPIDEMIOLOGY AND STATE

MEDICINE. IAT a meeting of this Section, held on Nov. 28th,

with Prof. MAJOR GREENWOOD in the chair, a

discussion on

Food as a Preventive of Disease

was opened by Dr. J. M. HA3vflLL. Well-being,he said, was dependent on two factors, heredity andenvironment, and of these heredity played a partwhich was often under-estimated. The most intimateand powerful of all environmental influences was food.By means of proper food an individual’s hereditaryequipment could be developed to greater advantagethan by any other environmental means. The body,when properly fed and well nourished, had

extraordinary powers of resistance to disease. Theincidence of tuberculosis in a community appearedto be closely correlated with the food-supply, diminish-ing when the supply was ample, and increasing whenthe quantity or quality of the diet was inadequate.Troops could withstand great hardships when rationswere plentiful and suited to their needs. Duringthe Middle Ages the relationship between famine andpestilence was well understood. It was not a simplematter to say with certainty what was sufficientand suitable food, or when a diet might be regardedas completely satisfactory, but variety of the rightkind would, in most cases, go a long way towardsensuring adequacy.

Inadequate diet conduced to maldevelopmentand lack of resistance to disease. Specific instanceswere rickets, defective teeth, scurvy, beri-beri,pellagra, goitre, and a peculiar form of ophthalmia.These diseases were, moreover, only the advanced

stages in a long train of disordered metabolicactivity which in its earlier stages produced effectsso slight as to elude all means of detection at

present available. Most of these disorders resultedfrom deficiencies in the diet, that is, were due tonegative factors, but in the production of rickets apositive factor contained in cereals might also play apart. A correct diet depended not only upon thepresence of the necessary constituents, but upon theirproper balance ; adequacy in respect of one essentialconstituent might be converted into inadequacywhen the balance in respect of some other constituentsof the diet was altered. It was possible, however, toensure a satisfactory diet for all practical purposes byrelatively simple means if certain foods such as milkand green vegetables were prominent. IAnother aspect of nutrition was the damage which

might be done to important constituents of food as aresult of processes which food might undergo in itspreparation for consumption. An obvious examplewas the destruction of the antiscorbutic vitamin bydrying or heating. Another instance might be thedestruction of the colouring matter of flour bybleaching. This colouring matter was carotene,which would seem to be a precursor of vitamin A,and it might be that in certain circumstances the

body could rely upon this carotene for an importantproportion of its vitamin-A supply. The treatmentof fruit by hydrogen cyanide for the destruction ofinsect life exerted an inimical effect upon the living

cells of the fruit, and impairment of nutritive valuecould not be said to be excluded. Biological researchtended more and more to emphasise the importanceof the infinitely little in the processes of metabolism.Slight changes in composition resulting from manipula-tion might produce changes out of all proportion in thenutritive value ’of a food.

DISCUSSION.

Sir GEORGE BUCHANAN said that with regard togrowing children and adolescents there was no doubtthat vitamins, particularly vitamin D, were necessary,and it was better to have excess than not enough;but in the case of adults on ordinary mixed diet, hewondered how far the presence of a certain amount,more or less, of a particular vitamin was an essentialthing to watch. Was it vitally important to have sucha discrimination of diet as would provide the particularvitamins the absence of which might conceivablyproduce scurvy, beri-beri, or rickets? An exaggeratedimportance seemed to be attached, in the case ofthe adult, to the need for getting vitamins in

quantity, when, as a matter of fact, a very smallamount of vitamin was all that was necessary tometabolism:

I Sir WILLIAM HAMER said he was sceptical of a gooddeal of the work on vitamins until the experience ofthe war. That experience was very arresting.The ordinary members of the public were able invarious ways to supplement the strict rations. but thepeople in institutions who had no such opportunitiesexhibited various effects of deprivation. In the

big fever hospitals it had been the practice for manyyears to give margarine instead of butter. Oughtthat to be permitted ?

Dr. KINGSTON BARTON said that 50 years agorickets was regarded ’as due to excess of starch.All the children suffering from rickets seen in privatepractice in those days had been stuffed with bread,under-cooked flour, and the various patent foodsof the period. Some of the physicians in thosedays showed that starch if boiled, cooked, or con-verted into dextrin could be made much less harmfulfor children. ’

I Dr. W. CRAMER remarked that deficient dietsdid not merely produce specific diseases, but a longchain of ill-health of which the specific disease wasonly the last event. The early stages were extremelyelusive. The reason why these conditions were moreobvious in the case of children was that when a childwas ill from any kind of disease it stopped growing.These specific diseases were due to pathologicalchanges. So far as his own experimentswere concerned he had never been able to convincehimself that vitamin D was necessary for the adult;it seemed to be solely concerned with the ossificationof bone. ’

Dr. THOMAS CARNWATH said that the main resultof modern scientific research into matters of food hadbeen to justify traditional practice. He recalled,in his own early days in the west of Ireland, seeing thelabourers whose normal diet consisted of potatoes,

butter-milk, and perhaps sometimes a little tea andpork, but they we fine strapping fellows nevertheless.When, however, they came over to help in the English! harvest they were overfed with protein, and it tookthem a couple of months to recover. The conditionsof life, Dr. Carnwath added, were becoming more and

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more artificial, and the question was whether thecommunity was modifying its dietetic habits to correctthe evils inherent in these changes. It was there,perhaps, that the scientific man could give assistance.It was only by careful and intensive investigation ofdiets that it was possible to ascertain what the foodhabits of different sections of the people were, and inwhat respect they were defective ; having ascertainedthat, it might be possible to graft on the slight modifica-tions necessary to bring them into conformity withscientific principles.Dr. S. A. MONCKTON COPEMAN commented on the

changes in the views on dietetics which had takenplace within recent times. Was it not possible thatthere were one or two other factors of importance inaddition to vitamins, for example, the aesthetics ofnutrition ? There was not the slightest doubt thatif a person enjoyed his food lie was all the more likelyto benefit from it. Many of the diseases of adult lifemight be’ connected with the over-ingestion ofvitamins, particularly of animal origin. The consump-tion of watercress, which contained various vitamins,was urged by Xenophon upon the Persians-anotherinstance of the wisdom of the past.

Dr. H. C. CORRY MANN thought that in the pastinsufficient attention had been directed to diet in the

prevention of disease. He pointed out how greatlyof recent years the health of London children hadimproved, although the housing conditions in theLondon slums remained the same. Two food modifica-tions had been responsible for this betterment-

namely, the use of pasteurised milk, and the fact thatthere was now available a large supply of fruit, such asthe orange and the apple, throughout the year.Summer diarrhoea and abdominal tuberculosis hadalmost disappeared. He advocated strongly the

pasteurisation of milk. If pasteurisation were

properly performed, scurvy would not be seen, andthere would be a normal increase of growth rate.He also stressed the importance of water. Hebelieved water to be very important because itallowed the necessary alkaline basis to be kept insuspension in the tissue fluids.Dr. H. S. STANNUS said that in many of the so-

called deficiency diseases the symptoms were positive,not negative; they were produced by the presenceof something, not by the absence of something else.He was convinced that pellagra was not a deficiencydisease. It was due to the action of a toxin, andwas unmasked in the absence of the vitamin. Thesame was true, he believed, of rickets and of beri-beri.

Fleet-Surgeon W. E. HOME referred to the. recentpublication in Germany of some research carried outin Hamburg, where it was found that the diet of

many of the working people was poor in the winter,and especially towards the end of the winter. Thedeath-rate had two maximums, one in December andone in March. It had also been established thatinfectious diseases were less likely to occur in thefamilies of people who had gardens.

Dr. J. D. ROLLESTON remarked on the absenceof any authoritative information as to the vitamin.content of wine and alcoholic liquors of which so

much was made.

The PRESIDENT, in summing up, said that in a

country like this, which was not self-supporting, andwould starve on its own resources in a short while,we did not receive the food we liked, but the food wewere forced to purchase through existing commercialconditions.

SECTION OF ORTHOPAEDICS.

AT a meeting of this Section held on Dec. 2nd thechair was taken by the President, Mr. P. JENNERVERRALL. Dr. L. B611LER spoke on the treatmentin Vienna of

Fractures of the Upper Extremity.He showed slides and cinematograph films illustrat-ing his methods. He recommended local anaesthesiafor all fractures ; it was particularly valuable in

compound fractures. It was sufficient to inject20 c.cm. of 2 per cent. novocain into the hscmatoma,as this spread the anaesthetic into all the tissues.He had injected over 5000 cases and had never seeninfection. The anaesthesia lasted about two hours,thus allowing for a second reduction and fixation ifthe first proved unsatisfactory under X rays; if

necessary the injection could be repeated. Dr. Bohleralso recommended Cramer’s wire splinting for mostcases. It formed the basis of the " aeroplane "splint for fracture of the middle third of the humerus.This was very difficult to fix, but when it was properlyfixed the patient was free from pain and could wearit for six or eight weeks. It could not be appliedsatisfactorily under general anaesthesia. After twoweeks the patient could use his hand and forearmand even move his shoulder muscles, while still onthe splint, and after ten weeks recovery would becomplete.

Fractures of the lower third of the humerus showed

angulation and overlap. If the overlap was notreduced by traction there was a risk of nipping thebrachial artery between the upper fragment andthe coronoid process. Supination always increasedthe angulation, and the result might be musculo- *-

spiral palsy, but pronation corrected it. The armwas therefore put up in plaster in right-angled flexionand pronation, and then fixed in an aeroplane splintwith an extension device. After ten weeks all jointswould be free and the muscles strong. The aeroplanesplint was also the best application for fracture ofthe neck of the scapula.For fracture of the clavicle he used an apparatus

which held the arm away from the chest by anaxillary pad, but did not press the elbow to thechest-a practice which brought a danger of pressureon vessels or nerves. This apparatus left the armquite free, and overcame the difficulty of keeping thefragments reduced while healing took place. Recoverywas complete in four weeks. If there was a recal-citrant middle fragment a secondary shoulder strapcould be used to hold it in place. Even fracture-dislocation of the shoulder-joint should be treatedby closed methods. Dr. Bohler demonstrated howthe head could be reduced by alternate lateral pullingand upward pushing ; the arm was then treated onan aeroplane splint with extension.

’ In myositis ossificans it was important, he said,not to operate too early, and the bone must beremoved together with its periosteum.

THE FOREARM AND HAND.

For the reduction of severe forearm fractures,with both bones broken and displaced, the brachialplexus should be injected with novocain. Counter-extension was obtained by passing a loop of webbinground the upper arm, blocking the loop open to

prevent pressure on the limb, and fastening its endsto the wall or door-handle. The fingers were thenpainted with mastisol and covered with a light gauzebandage. On this an assistant took his grip and exerteda very strong slow pull. When reduction was effected

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rustless wire was drilled through both bones at theirupper and lower ends-still under traction-and thearm was put up in plaster, flexed and pronated.Small volar and dorsal rods were placed in the inter-osseous space, and after the application of the circularbandage these were pressed home. Small lock screwsin the plaster held the wires, and the arm was put onan aeroplane splint for two or three days to preventcirculatory disturbances. In more than 40 cases

Dr. Bohler had seen no infection; he also used this

wire-drilling method for complicated fractures of thecarpus and lower end of the forearm. It was ’,important to remember, he said, that bony union ’i,never occurred, in complete transverse fractures withdisplacement, in less than eight weeks. His methodof treating pseudarthrosis was by drilling groovesat the ends of the bones ; it differed from the similarprocess described in the British Journal of Surgeryin 1914 in that the drilling was usually done sub-cutaneously.For difficult fractures of the lower end of the radius

a similar method was used ; it was very importantthat the assistant should maintain continuous tractionwhile the fixation was applied, and that he should havesomething against which to brace his foot so that itdid not slip. For simple Colles’s fracture only gauzebandaging and a splint were used. Active movementsbegan as soon as the cast was set, even after verysevere injuries; patients could dress themselves,make their beds, knit, and cook three days after theinjury, and these natural activities had great thera-peutic value. Two weeks after removal of the splintrecovery should be perfect. ̂ ^ - - IA fracture of the little finger (first phalanx) was

put up in a U-shaped wire splint fastened to the wristby plaster ; the finger was attached to the wire inhyperextension by adhesive strapping, and the fracturereduced by gradual bending of the wire. Fracturesof the scaphoid always united if properly fixed foran adequate period-six weeks. These injuries wereseldom fixed for sufficient periods. Often the central

fragment was deprived of its circulation by the

fracture, and the re-establishment of its blood supplysometimes demanded months of fixation, but thepatient could go on working during this time if hishand was in plaster in slight dorsiflexion. Everytime he closed his fingers he axially compressed thescaphoid, which helped the treatment. Dr. Bohlernever removed the scaphoid, as the function of thehand did not seem to be much improved by operation.Dislocation of the semilunar bone could be reducedby strong traction in recent cases, but older casescould be treated in an extension apparatus with pinsthrough forearm and metacarpus. In these old casesthe gap which the semilunar should occupy closed upand must be re-opened. Similar methods were

applied to other dislocations round the wrist. Com-pound fractures of the fingers were treated by closureof the skin only and a wire extension on the uncoveredfinger; exposure to air prevented maceration andinfection, the serum and blood forming a dry crustwhich protected the skin. If a dressing were puton the serum and blood soaked it, infection followed.

DISCUSSION.

Mr. E. G. SLESINGER mentioned the heavily-infected compound fracture when it came too late forprimary suture. He had found in Gallipoli that themore maggots there were in a wound the better theend result, and that Dakin’s solution dissolvedprotein. Nature’s method was to supply maggotsto eat the dead tissue, and the deliberate use of hermethod had given good results. After four days the

maggots could be gently scraped away from a cleangranulating wound.

Mr. C. H. BROOMHEAD said that teamwork wasthe secret of Dr. Bohler’s success, and we had much tolearn from him. The position he used for fracturesof the humerus was a great advance. He asked howto treat separated epiphysis. He thought the mentalstate of the patient covered with maggots wasregrettable. Dr. Bohler had not a masseur in hisclinic ; often the injudicious masseur did more harmthan good. The patient was the best indicator of themovements suitable for him.

Mr. J. P. HOSFORD said that what had mostimpressed him in Dr. Bohler’s clinic was the absenceof general anaesthesia and of massage. He had seenremarkable results with local anxsthesia. Earlymovement saved subsequent stiffness, but was onlypossible with a perfectly fitting splint. He had givenup massage for fractures of the upper end of thehumerus and lower end of the radius, allowing thepatient to move about in a plaster cast. It wasremarkable what good movements could be obtained.

Mr. MCCRAE AITKIN regretted the absence of SirRobert Jones, who had long ago preached length andcontinuity of treatment. As Dr. Bohler had said,true principles never changed, but each man madehis own technique.

Mr. G. R. GIRDLESTONE asked if the hairs came offwith the plaster.

Mr. W. H. OGILVIE asked how long after thefracture local anaesthesia was possible, and how theplaster was removed.

Dr. BÖHLER, in reply, said that wounds could onlybe closed within the first six hours after fracture.The great feature of treatment was uninterruptedrest. He had had the same experience with maggots,and had seen wonderful results from their use in

osteomyelitis in childhood. Reduction of the

epiphysis was not difficult, but traction must be com-bined with bending movement. Simple local anees-thesia could be used as long as there was a hsematoma,sometimes as long as two weeks after injury, butwhen the haematoma had gone infiltration could beused. He never shaved or anointed the skin, becausethe hairs gave the plaster good fixation and did nothurt when they were all pulled on together. Whenit was removed four or six weeks later new hairs had

grown and were therefore not incorporated in the cast.

LIVERPOOL MEDICAL INSTITUTION.

AT a meeting of this Institution on Nov. 20th Dr.L. J. PICTON read a paper on

Amylaceous Dyspepsia.In this condition, he said, dyspepsia was noticed tofollow starchy meals. A starch-eating habit wasrecognised, and cure followed abandonment of thehabit. The form of starch was important; unburst

granules, such as those in the gluten framework ofthe bread sponge, were insusceptible to the influenceof ptyalin. Slimy gastritis might be caused by exces-sive, especially unburst, starch as well as by infectivecatarrh. Delay might be caused not only by slimygastritis, but also, normally, by eating starch andmeat together (Pavlov) as in the conventional dietary.The satiety necessary for the tranquility of thestomach could be achieved by taking meat and

greens. An equal filling of starch and meat involvedunnecessary digestive labours as well as delay, but