494

justifiable without a bacteriological examination.It was reported that the Streptococcus scarlatinœpersisted for some three to six weeks after the symp-tonxs had subsided.

Sir FREDERICK ANDREWES discussed the questionwhether there was such a disease as scarlet feverclinically—i.e., whether it was a sharply definedentity, or whether it shaded off into other strepto-coccal manifestations, so that it was difficult to saywhat was scarlet fever and what was not. lIe hadseen, in 35 years, hundreds of cases of doubtful scarletfever from the wards, the origin of the infection beingundetermined. The same sort of difficulty wasencountered in regard to the bacteriological evidence.Was it always the same kind of streptococcus whichcaused recognisable scarlet fever ? Dr. Griffith haddeclared that there were three different serologicaltypes of streptococci which could be obtained fromthe throats of scarlet fever patients, and the two sortswhich were commonest in this country were notthose which seemed to be commonest in the UnitedStates. Might it not be that in scarlet fever therewere several different races of streptococci whichformed one common toxin ? A lady who was workingin his laboratory had last summer got what was,clinically, acute rheumatic fever. She had been givensome of Dr. O’Brien’s concentrated antiscarlatinalserum with strikingly beneficial results. When, later,she had a relapse, another dose of it caused thetemperature to come down to the normal in four hoursand the pain to disappear from the joints.

Dr. ALEXANDER JOE agreed that in London, owing-to the mildness of the infection, there was littleopportunity for judging of the clinical value of thisserum ; in Edinburgh the disease was definitely moresevere. Until he came to London he had not realisedwhat serum sickness was; he did not know whetherthis was due to the greater sensitiveness of the childrenin the south or to the type of serum supplied forLondon. He thought a reason why good results didnot follow in septic cases was that the serum was gener-ally used too late. As to Sir Frederick Andrewes’sremarks, Dr. Joe had heard a laryngologist say thatafter mastoid operations his patients often goterysipelas, whereas after r tonsillectomies a muchcommoner sequel was scarlet fever.

Dr. C. J. MARTIN asked whether there was experi-ence of an epidemic spread of any other form of strepto-coccal infection, such as occurred in scarlet fever.

Dr. J. E. MCCARTNEY referred to the case of ahospital maid who had scarlet fever, and contractederysipelas when she was partially recovered fromthe first infection, After that, when the temperaturecame down, she had pyaemia and a haemolyticstreptococcus was isolated from the blood. Muchmore work was needed before laws cou ,d be laid downabout the degree of infectivity of cases of scarletfever. Much light might be gleaned by a close studyof the organisms responsible for the failures.

Dr. H J. PARISH described experiments on thetitration of scarlet fever antitoxin in rabbits (videTHE LANCET, Jan. 8th, p. 7t).

Dr. GooDALL and Dr. O’BRIEN replied.

POST-GRADUATE HOSTEL.

THE final meeting of the Hostel was held at theImperial Hotel on Feb. 24th, when Sir D’AR,cyPowER opened a discussion on

Chronic Ulcers of the Tibia.These he grouped into non-infective, infective, andmalignant. Of the non-infective, he said, the com-monest were the traumatic and the varicose. Lessoften seen, and nearly always in women, was thesmall rather punched-out ulcer which gave verygreat pain, probably because there was a nerve-ending in the centre. These could be cured byblistering or painting with silver nitrate. Firstamong the infective was the tuberculous, for thesyphilitic was by no means the commonest, as was

often supposed. lie had seen enormous numbersof osteomyelitic ulcers in Ireland, but fewer in thiscountry. The infection started in the bone, extendedthrough the skin, and ended as a chronic ulcer,usually associated with sinuses. Another and different

type of ulcer was that associated with gangrene.He had seen large numbers of carcinumatous ulcersin regions where cancer appeared t" he endemic.Malignant ulcers of the tibia were apt to go on fora very long time before killing the patient.

Treatment.Dr. G. F. STEBBING spoke of his experience of

ulcers in a Poor-law hospital where very largenumbers were encountered. For over 15 yearshis institution had kept a ward of 90 beds for nothingelse. The important points in treatment were

cleanliness and early attention. An injury might healquickly, but the resulting scar often had not enoughblood-supply to stand active life ; every little knockstarted the trouble again and finally periostitis setin. Such cases did best if the scar were excisedand the area grafted on to the deep fascia. Much moredifficult to treat were ulcers arising on a leg withfaulty circulation, as with varicose veins and phleg-masia. One-third of his cases had been in womenwith a history of "white " leg after parturition,and in such women he had seen ulcers extendingfrom knee to ankle and all round the leg. Amputationwas the only treatment for most of them. but evenulcers of this class might heal after a time withthe leg at rest in a raised position and with antisepticdressings which were not changed too often. Thecomplication of conservative treatment was thatstasis produced adhesions in the tendon sheaths,with the result that the ankle appeared ankylosed,though really the lameness was due to matting ofthe tendons. Therefore it was not really worthwasting time healing up the ulcer if amputationcould be performed. Some of the cases had septicinfection through the deep fascia, and pus pouredfrom the ulcer. The varicose ulcer was oftenassociated with only a very slight degree of varicosity.but the circulation was always poor. The ulcerationseemed to depend largely on the recurrent phlebitisthat affected the varicose veins. It healed quicklyand the leg kept well if the patient could be per-suaded to sleep and spend a part of each day withher foot raised. The pain was ischaemic in natureand was greatly relieved by a wedge under themattress, 9 inches high at the broad end. Hoskinsmade a special bed for such cases. Dr. Stebbingsthought that parathyroid was not of much use.

An elastic stocking was better than bandages ifthe patient could afford to have a really well-fittingone, renewed about twice a year. If there werevaricose veins about the knee the stocking must bein two pieces so that bending the knee did not produce! anaemia. Unfortunately patients had to earn theirliving, the leg got knocked, and the ulcerationreturned.The Poor-law officer, Dr. Stebbing continued,

saw very little tuberculous ulceration, and syphiliticulcers, like all tertiary syphilitic phenomena, werebecoming rarer and rarer. He had seen many ofthe so-called gangrenous ulcers, but they were notgangrenous in the ordinary sense of the term.The condition began as a little spot which rapidlyspread over the leg until the skin sloughed and leftan ulcer. This healed well and rapidly if treatedwith antiseptics, but if it were treated as an indolentulcer for a long time and got a hard edge it woulddo badly, and matting of the tendons would probablyoccur. Osteomyelitic ulcers were becoming moreuncommon as treatment improved ; nowadays theywere more often seen over the femur than over thetibia. One type of malignant ulcer began as a papuleand grew without previous ulceration, startingapparently as a true carcinoma of the skin ; -, a

commoner form began on the site of a varicose ulcerand was seen also on the foot, even on the great toe,at the site of some chronic sepsis such as a bunion.

495

Dr. P. F. WATKIN said he had found lotio calaminsevery useful, and for tropical ulcerations lie recom-mended irrigation by dropping methods or by soakingthe leg for hours in a bath. The chief features oftreatment were cleanliness, rest, and the applicationof an antiseptic, such as perchloride with a little salt.

Dr. STEBBING agreed that the probletn was howto keep the part clean. The bath was not verycomfortable, and he had found boric compressesbetter when once the skin was clean. All kindsof hyperæmic methods were useful-kaolin, glycerinepastes, radiant heat, massage, and electricity. Ifthe scar were soft and could be pinched up recurrencewas unlikely.

Dr. A. P. BERTWISTLE said that traumatic ulcersresulted from bruises and abrasions which wereso insignificant that they were neglected. Thecauses of chronicity in an ulcer were : (1) Poorblood-supply. The deep fascia, the duty of whichwas largely to carry and support blood-vessels,joined with the periosteum of the tibia over itssubcutaneous border, so that there were few vesselsin the area. (2) Such ulcers became fixed at anearly stage to the bone, which cut off the vascularsupply to their base. If periostitis did not occuras the result of the blow, it would develop later.(3) The exposed position militated against rest.

(4) The absence of fat in the subcutaneous fasciameant that there was no cushion to break theimpact of a blow or make the part elastic. (5) Thedependent position was not conducive to a goodblood-supply. Abrasions, he said, should be allowedto dry, the resulting eschar being the best protectivefor them. In America they had tried electric dryingas in shampooing. If dirt were ingrained hydrogenperoxide was beneficial for a day after which thewound should be allowed to dry. Lotio calaminæ

worked like a charm in some cases. Rest in bedwas essential if there were varicose veins. Iodoformclisguised the smell of putrefaction, but iodine wasbad and caused much pain. Boric ointment ina paraffin basis was useful at certain stages.

ROYAL ACADEMY OF MEDICINE INIRELAND.

SECTION OF OBSTETRICS.A MEETING of this Section was held on Feb. 4th,

Dr. Louis CASSIDY (in the absence of the President)in the chair, when Dr. BETHEL SOLOMONS read a com-munication entitled

Rupture of the Uterus Treated by Plugging the Rent.The patient was aged 35 and had had three normal

labours. During the second stage of labour her doctorhad given her 1 c.cm. of pituitrin and as there was no advanceafter an hour had applied forceps and delivered a stillbornchild. Efforts to express the placenta and to remove itmanuallv had failed.On admission she was pulseless and in a condition of

profound shock, just conscious. Routine treatment showedlittle reaction and the placenta was sought for. The cervixwas closed, but on following the cord it was found that theuterus was separated from the fornix on the left side andthat the placenta was among the intestines ; it was removed.Intestines appeared at the vaginal vault and the rent wasplugged with a large tampon of iodoform gauze. Twodays later symptoms of intestinal obstruction appeared,and the gauze was removed. For 14 days she got on well, but there was always some distension without absoluterigidity. Symptoms of slight peritonitis then appeared ’,and the abdomen was drained ; two pints of foul sero-

sanguinous fluid escaped and a drainage-tube was inserted.Since then, said Dr. Solomons, she has progressed

well, but there was still some discharge from thewound. which it was hoped would clear up withultra-violet rays. This patient would have died hadlaparotomy been done ; she had lived after thetreatment of plugging. Plugging was a valuableaid to obstetrical teclmique and could be carriedout by the general practitioner. The rupture hadoccurred probably from the overdose of pituitrin

in the second stage of labour. 1 c.cm. was far toolarge a dose. If pituitrin was given at all, two orthree minims should suffice, and it should only begiven in selected cases.The CHAIRMAN agreed that when a patient came

to hospital in a condition of shock, as in thiscase. there was nothing to be gained by laparotomy.Most of these cases, if they did not die of shock,died from sepsis within ten days. He mentioned thestatistics published by Doderlein from cases ofrupture of the uterus at the clinic at Munich duringthe last 50 years, when there had been 50 cases.

Seven of the cases had been untreated and haddied. Ten had had laparotomy performed, and ofthese 60 per cent. had recovered. The other caseshad been treated in various ways. Eight of themhad been treated in a way similar to that describedbv Dr. Solomons and three had recovered. On thewhole the average of recovery had been between40 and 50 per cent. during the last 50 years. Hethought that in this case the large amount of pituitrinwhich had been given was probably responsible forthe condition. If cases were not too shocked he

thought they were better treated by laparotomy ;but a great deal depended on the method by whichthe shock had been brought about, and also on thetime which has elapsed since the rupture had takenplace and when the patient was seen.

. Mr. W. PEARSON said that it was very difficult

in this case to decide what to do after the primaryshock had been overcome. It was a question ofeither peritonitis or intestinal obstruction. It proved,however, to be an obstruction, and the patient haddone fairly well for a fortnight. After that timethe temperature had risen and the abdomen hadbecome distended and soft ; but it was plain that itwas not an obstruction, as the bowels moved ifpurgative or enemata were given. There was a gooddeal of dullness in the right iliac fossa, extendingacross to the middle line, and the probability was thatit was a case of mild peritonitis. The abdomenwas opened, and peritonitis was found; there wasa great deal of turbid fiuid and also adhesions thewhole way across to the abdominal wall.

Dr. CANNON said that these cases were rare.

He personally had only come across two. One wascaused bv the injudicious use of pituitrin, and thebaby had died. The other was a case of spontaneousrupture from a previous scar. He did not think thatthere was any great danger of sepsis if the gauzewas left on for 10 or 15 days. He thought that ifthe foetus was completely in the peritoneal cavityit would be difficult to deliver the baby, unless thescar was extended ; and it would add to the shockto deliver the baby per vaginam. In these cases hethought laparotomy should be done.

Prof. DAVinsoN asked where the rupture was inthis case ; was it in the uterus or not ? He had hadthree cases of rupture of the uterus, two followingversion and one following a breech. In the firstcase the rupture had been discovered when tryingto extract the placenta ; the rupture was in thefornix. The placenta was removed by traction ofthe cord and the hand was never inserted at all.He thought that this was a very good point in tech-nique, as in this way it might be possible to avoidintroducing sepsis into the abdominal wall. In allhis cases the wound had healed. He asked if therewas any possibility of the collection of fluid in theabdomen being urine, as he thought perhaps thebladder had been injured by the rupture, as sometimesthe bladder was concerned in cases of ruptured uteri.

Dr. SOLOMONS, in reply, said that he had met threecases of rupture of the uterus in the past three months-the one he had reported, which lived ; one of quietrupture which died ; and another one which occurredon the previous day where there was a spoutinguterine artery. In this last case hysterectomy hadbeen necessary and the patient was still alive. Plug-ging was the best treatment when possible, but therewere some cases in which laparotomy alone couldbe done. The practitioner must choose his case for