THE SECTIONS. THERAPEUTICS AND PHARMACOLOGY
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790 as Dr. Charteris had done at a time when extravagant claims were often made for proprietary articles. Professor DIXON read a paper entitled I I Facts and 11’aneies in Pharniaeology. " Tie said that many of our explanations of disease and of the action of drugs were not dependent upon sound physio- logical experiment. We had all been brought up in a school of dogmatism and taught to accept certain statements as proven. The length of time occupied in the teaching of anatomy and of materia medica dated back to an age when these formed almost the whole of the preliminary training -of the student. We no longer collected our own simples or prepared our galenicals, and yet we had not materially -altered our teaching. In this way a useful knowledge of the I true action of drugs was excluded. Tradition still endowed - certain drugs with actions which they did not possess. Opium was devoid of local action, yet there were in the Pharmacopoeia three preparations for local application. Hydrocyanic acid was prescribed for the local relief of gastric pain in doses far too small to have any action at all. In the case of digitalis, modern research had succeeded in altering the accepted views. In 1851 Neligan stated that digitalis enfeebled the action of the heart, and this was at the time :generally accepted. The same could not be said in the case of ether and strychnine. Neither had any direct stimulatory :action on the heart as was often supposed and taught. Belladonna had no action in stopping the secretion of milk, for atropine could only act upon nerve endings, and the mammary gland was without nerves. Salts of potash were regarded as depressant, yet vegetarians were accustomed to take as much as 80 grains per diem. Potash was only poisonous in a certain concentration, and experiments which he had carried out showed that when given by the mouth it was excreted more rapidly than it was absorbed, so that the concentration in the blood increased very little. Calcium given by the mouth is also slowly absorbed and rapidly excreted. Injected under the skin, on the other hand, it may have a powerful effect in increasing the coagulation time of the blood. Dr. J. C. McWALTER, in a paper entitled " We Regulation of Quack Medioine Trraffia," said that since the British Medical Association last met 2,400,000 had been spent on quack medicines in Great Britain and Ireland. The gain to the Government bad been 300,000. The concurrence of the Government in this traffic had become a national scandal. Other countries had been careful to legislate on the matter and the colonies were grappling with the problem. The solution of the trouble was that makers of nostrums should be compelled to set forth the ingredients on the label. To attain this an Act of Parlia- ment would be necessary, and he feared that the profits of the Government were too large to render it likely that it would so legislate. He thought that the greatest service had been done by the British Medical Association in pub- lishing, as it had recently done, the composition and cost of certain of the most widely advertised drugs. He regretted that it was difficult to bring these results before the public because newspapers, whose advertisement columns were profitably filled by the proprietors of secret remedies, were little likely to join in the crusade. He believed that the best means of attack was by cooperation with the medical officers of health. Already a notable beginning had been made in Liverpool, where Dr. E. W. Hope had prosecuted a proprietor of a patent medicine. He was charged under the Sale of Fond and Drugs Act for selling drugs not of the nature, substance, and quality demanded, and a conviction was obtained. If such action became general, and the publica- tion by the Association of the composition of so many unduly advertised drugs had made that possible, he thought that much might be done to control the traffic. FRIDAY, JULY 30TH. Dr. H. D. ROLLESTON (London) opened a discussion upon The Treatment of oedema. He adopted the following classification of oedema. 1. The oedema of venous obstruction and cardiac disease, primarily mechanical and due to hydrostatic factors, as was partly shown by the influence of gravity. Hydrasmia and mal- nutrition of the capillary endothelium were active agents also in its production. 2. Renal dropsy, though sometimes mainly cardiac, as in granular kidney, was in its proper sense of complex pathology. Toxic factors were probably predominant, but hydraemia and retention of chlorides must also be taken into consideration. 3. Toxic oedemas other than those due to manifest renal disease. For example, the oedema sometimes seen in infective diarrhoea in children, and the critical cedema seen in rare cases in pernicious ansemia. 4. Inflammatory oedema. 5. The cedema due to thrombo-phlebitis depending on venous and lymphatic obstruction. 6. (Edema due to lymphatic obstruction. 7. (Edema due to nervous factors : (a) oedema associated with peripheral neuritis and beri-beri ; and (b) hysterical cedema. 8. (Edema of doubtful origin-e.g., chronic troph- cedema, sometimes known as Milroy’s disease. He would confine himself to the treatment of cardiac and renal cedema. 1. In cardiac dropsy, although primarily of mechanical origin, the treatment was sometimes rendered difficult because a toxic factor, from intestinal toxaemia, or renal insufficiency, might be added. The mechanical break- down was to be met by rest and by the use of digitalis. Professor Dixon had shown that samples of the tincture of digitalis may be devoid of any active principle, and it was therefore important to choose the preparation with care. He recommended the fluid extract of the drug. Nativelle’s granules were also often successful, as was the combination of caffeine and digitalis recommended by Sir James Barr, or a similar combination of theocin or diuretin with digitalis. Theocin acetate was less irritating and less likely to pro- duce vomiting-than theocin. Baillie’s pill had a deserved reputation. The restriction of fluid to 25 or 30 ounces in the 24 hours was an important part of the treatment. The restriction should be gradual and progressive so as to avoid thirst and constipation. The intake of salt should also be limited and gentle massage was often useful. 2. The com- plicated pathology of renal dropsy made it difficult to estimate the effects of treatment, and sudden improvement might be independent of treatment. He quoted three cases in which sudden diuresis and disappearance of dropsy had set in appar- ently independently of the treatment adopted. In four days in this way a patient had lost four stones and three pounds in weight. The very rapid absorption of a large amount of cedema fluid was a possible source of danger and might cause urasmic symptoms. The occurrence of dropsy might thus be regarded as a conservative process. He believed that this was true in acute nephritis. Toxins in the circula- tion damaged the walls of the capillaries and so led to transudation of fluid. Removal of these toxins might be attempted by free drinking and the copious fluid regimen, especially milk, might be combined with purgation. But this plan would not succeed if the kidneys were incapable of dealing with the increased amount of fluid. There was a danger of hydrasmia resulting. Copious drinking should be avoided in acute or subacute nephritis. The use of diuretics required care, for the kidneys might be unable to respond or might be irritated by the diuretic drug. Caffeine he had found more successful than diuretin or theocin. He believed that greater benefit followed the removal of fluid by means of hot-air baths than by means of restrict- ing the intake of fluid. The most satisfactory way of removing the toxins was probably by incising the legs. He recommended a single incision on the dorsum of the foot. No hard-and-fast rule could be laid down as to the restriction of fluid. In some cases the kidneys could only deal with a small amount of fluid, and unless the intake was curtailed hydrasmia resulted. In other cases the kidneys could deal with an increased ingestion of fluid. That chlorides might be retained in cases of parenchymatous nephritis was undoubted, but it was not proved that in all cases the relation of cause and effect was the same. In some cases the chloride retention was caused by the dropsy, in others it was itself the cause of the dropsy. It must be clearly recognised that a salt-free diet was often disappointing. Sir JAMES BARR (Liverpool) said that he divided cedemas into the following two great groups: (a) Those in which there was abnormal transudation from the capillaries without apparent obstruction in the absorbents, as in inflammation, in vaso motor paralysis, in anasmia, in Bright’s disease. (b) Those in which there was obstruction to the return current, whether local or general, such as the occlusion of a vein or lymphatic, portal obstruction from mitral or tricuspid disease, or obstructive lung disease. The treatment of oedema was theoretically one of the simplest problems in
Transcript of THE SECTIONS. THERAPEUTICS AND PHARMACOLOGY
790
as Dr. Charteris had done at a time when extravagant claimswere often made for proprietary articles.
Professor DIXON read a paper entitled
I I Facts and 11’aneies in Pharniaeology. "
Tie said that many of our explanations of disease and ofthe action of drugs were not dependent upon sound physio-logical experiment. We had all been brought up in a schoolof dogmatism and taught to accept certain statements as
proven. The length of time occupied in the teaching ofanatomy and of materia medica dated back to an age whenthese formed almost the whole of the preliminary training-of the student. We no longer collected our own simples orprepared our galenicals, and yet we had not materially-altered our teaching. In this way a useful knowledge of the Itrue action of drugs was excluded. Tradition still endowed- certain drugs with actions which they did not possess.Opium was devoid of local action, yet there were in the
Pharmacopoeia three preparations for local application.Hydrocyanic acid was prescribed for the local relief of gastricpain in doses far too small to have any action at all. In thecase of digitalis, modern research had succeeded in alteringthe accepted views. In 1851 Neligan stated that digitalisenfeebled the action of the heart, and this was at the time:generally accepted. The same could not be said in the caseof ether and strychnine. Neither had any direct stimulatory:action on the heart as was often supposed and taught.Belladonna had no action in stopping the secretion of milk,for atropine could only act upon nerve endings, and themammary gland was without nerves. Salts of potash wereregarded as depressant, yet vegetarians were accustomed totake as much as 80 grains per diem. Potash was onlypoisonous in a certain concentration, and experiments whichhe had carried out showed that when given by the mouth itwas excreted more rapidly than it was absorbed, so that theconcentration in the blood increased very little. Calciumgiven by the mouth is also slowly absorbed and rapidlyexcreted. Injected under the skin, on the other hand, it mayhave a powerful effect in increasing the coagulation time ofthe blood.
Dr. J. C. McWALTER, in a paper entitled" We Regulation of Quack Medioine Trraffia,"
said that since the British Medical Association last met2,400,000 had been spent on quack medicines in GreatBritain and Ireland. The gain to the Government bad been300,000. The concurrence of the Government in this traffichad become a national scandal. Other countries had beencareful to legislate on the matter and the colonies weregrappling with the problem. The solution of the trouble wasthat makers of nostrums should be compelled to set forth theingredients on the label. To attain this an Act of Parlia-ment would be necessary, and he feared that the profits ofthe Government were too large to render it likely that itwould so legislate. He thought that the greatest servicehad been done by the British Medical Association in pub-lishing, as it had recently done, the composition and costof certain of the most widely advertised drugs. He regrettedthat it was difficult to bring these results before the publicbecause newspapers, whose advertisement columns were
profitably filled by the proprietors of secret remedies, werelittle likely to join in the crusade. He believed that thebest means of attack was by cooperation with the medicalofficers of health. Already a notable beginning had beenmade in Liverpool, where Dr. E. W. Hope had prosecuted aproprietor of a patent medicine. He was charged under theSale of Fond and Drugs Act for selling drugs not of the
nature, substance, and quality demanded, and a convictionwas obtained. If such action became general, and the publica-tion by the Association of the composition of so many undulyadvertised drugs had made that possible, he thought thatmuch might be done to control the traffic.
FRIDAY, JULY 30TH.Dr. H. D. ROLLESTON (London) opened a discussion upon
The Treatment of oedema.He adopted the following classification of oedema. 1. Theoedema of venous obstruction and cardiac disease, primarilymechanical and due to hydrostatic factors, as was partlyshown by the influence of gravity. Hydrasmia and mal-nutrition of the capillary endothelium were active agentsalso in its production. 2. Renal dropsy, though sometimesmainly cardiac, as in granular kidney, was in its proper
sense of complex pathology. Toxic factors were probablypredominant, but hydraemia and retention of chlorides mustalso be taken into consideration. 3. Toxic oedemas otherthan those due to manifest renal disease. For example, theoedema sometimes seen in infective diarrhoea in children,and the critical cedema seen in rare cases in perniciousansemia. 4. Inflammatory oedema. 5. The cedema dueto thrombo-phlebitis depending on venous and lymphaticobstruction. 6. (Edema due to lymphatic obstruction.7. (Edema due to nervous factors : (a) oedema associatedwith peripheral neuritis and beri-beri ; and (b) hystericalcedema. 8. (Edema of doubtful origin-e.g., chronic troph-cedema, sometimes known as Milroy’s disease. He wouldconfine himself to the treatment of cardiac and renalcedema. 1. In cardiac dropsy, although primarily ofmechanical origin, the treatment was sometimes rendereddifficult because a toxic factor, from intestinal toxaemia, orrenal insufficiency, might be added. The mechanical break-down was to be met by rest and by the use of digitalis.Professor Dixon had shown that samples of the tincture ofdigitalis may be devoid of any active principle, and it wastherefore important to choose the preparation with care. Herecommended the fluid extract of the drug. Nativelle’sgranules were also often successful, as was the combinationof caffeine and digitalis recommended by Sir James Barr, ora similar combination of theocin or diuretin with digitalis.Theocin acetate was less irritating and less likely to pro-duce vomiting-than theocin. Baillie’s pill had a deservedreputation. The restriction of fluid to 25 or 30 ounces in the24 hours was an important part of the treatment. Therestriction should be gradual and progressive so as to avoidthirst and constipation. The intake of salt should also belimited and gentle massage was often useful. 2. The com-
plicated pathology of renal dropsy made it difficult to estimatethe effects of treatment, and sudden improvement might beindependent of treatment. He quoted three cases in whichsudden diuresis and disappearance of dropsy had set in appar-ently independently of the treatment adopted. In four daysin this way a patient had lost four stones and three poundsin weight. The very rapid absorption of a large amount ofcedema fluid was a possible source of danger and mightcause urasmic symptoms. The occurrence of dropsy mightthus be regarded as a conservative process. He believedthat this was true in acute nephritis. Toxins in the circula-tion damaged the walls of the capillaries and so led totransudation of fluid. Removal of these toxins might beattempted by free drinking and the copious fluid regimen,especially milk, might be combined with purgation. Butthis plan would not succeed if the kidneys were incapableof dealing with the increased amount of fluid. There was a
danger of hydrasmia resulting. Copious drinking should beavoided in acute or subacute nephritis. The use of diuretics
required care, for the kidneys might be unable to respond ormight be irritated by the diuretic drug. Caffeine he hadfound more successful than diuretin or theocin. Hebelieved that greater benefit followed the removal of fluidby means of hot-air baths than by means of restrict-ing the intake of fluid. The most satisfactory way ofremoving the toxins was probably by incising the legs.He recommended a single incision on the dorsum ofthe foot. No hard-and-fast rule could be laid downas to the restriction of fluid. In some cases the kidneyscould only deal with a small amount of fluid, and unless theintake was curtailed hydrasmia resulted. In other cases the
kidneys could deal with an increased ingestion of fluid.That chlorides might be retained in cases of parenchymatousnephritis was undoubted, but it was not proved that in allcases the relation of cause and effect was the same. Insome cases the chloride retention was caused by the dropsy,in others it was itself the cause of the dropsy. Itmust be clearly recognised that a salt-free diet was oftendisappointing.
Sir JAMES BARR (Liverpool) said that he divided cedemasinto the following two great groups: (a) Those in whichthere was abnormal transudation from the capillaries withoutapparent obstruction in the absorbents, as in inflammation,in vaso motor paralysis, in anasmia, in Bright’s disease.(b) Those in which there was obstruction to the returncurrent, whether local or general, such as the occlusion of avein or lymphatic, portal obstruction from mitral or tricuspiddisease, or obstructive lung disease. The treatment ofoedema was theoretically one of the simplest problems in
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medicine. All that was necessary was to remove the causeand to restore and maintain the balance between intake and
output. It was in the removal of the cause that difficulties
began.Dr. W. S. LAZARUS-BARLOW (London) said that he
apologised for speaking on the present occasion, because itwas 15 years ago that he had made his experiments uponcedema, and from what he had heard that day the questionappeared only to have grown in complexity. He wouldconfine himself to the so-called mechanical cedema. Pressureas such was unable to increase the outflow of fluid from the
capillary wall ; indeed, since the skin, in comparison withthe walls of the capillaries and lymphatics, might be regardedas a rigid wall, he thought that any increased capillarypressure would of necessity increase the pressure within thelymph spaces outside the capillaries. An increased outflowof more highly albuminous lymph was said to be due to theso-called increased "permeability" " of the capillary wall.But the only evidence of this increased I I permeability " wasthis same character of the lymph. It was a glaring instanceof reasoning in a circle. He adhered to his original viewthat the fundamental causes of cedema were starvation and
poisoning of the tissue cells. He spoke favourably of
Sampson Handley’s operation of lymphangioplasty forcedema of the arm in carcinoma of the breast. At theMiddlesex Hospital he had seen marked relief follow theoperation in several cases.
Dr. CHARTERIS briefly referred to the limited valueof diuretic drugs in the treatment of renal oedema.Diuretin, he thought, was more reliable than caffeine in
stimulating the kidneys in disease. He emphasised the factthat in renal disease mercury, even in small doses, was badlyborne and readily produced salivation. As a preliminary tothe introduction of Southey’s tubes he recommended that theskin should be disinfected and then painted with a solutionof zinc-ichthyol, gelatin, or some other impervious dressing,and that the tubes should be inserted through this coating.This plan had been of value in preventing infection at theseat of puncture.
Sir LAUDER BRUNTON (London) said that he had foundbenefit in cardiac cases from a salt-free diet. Many yearsago he had repeated Ranvier’s experiments of ligature of therenal vein, which showed that while venous obstruction alonewould not produce cedema, dropsy followed if the vaso-motornerves also were divided. The nervous element in the pro-duction of cedema was well shown in some cases of angio-neurotic cedema. In a case of ulcerative endocarditis he had
involuntarily produced acute generalised oedema by the
injection of antistreptococcal serum. Calmette had foundthat the addition of lecithin to cobra venom conferred on it a
haemolytic power like that of viperine venom, and that
suggested that possibly in the future we might be able toconvert any cedema-producing toxin into one which had acontrary action.
Dr. CAMERON said that he thought that sufficient
praise had not been given to the salt-free diet as
a method not of treating nephritis but of combatingoedema. In many cases of nephritis the daily curve of thebody weight followed so closely the curve indicating theretention of sodium chloride in the body that the corre-
spondence could not be accidental. He emphasised theimportance of recording the body weight as the only accuratemeans of estimating the subsidence or increase of oedema.It was generally held at the present time that diaphoresiswas a more potent means of removing cedema than purga-tion, and active purgation had to a large extent been aban-doned as routine treatment. It was interesting to note thatwhile the sweat was rich in sodium chloride, analysis of thefasces revealed only traces of the salt.
Dr. W. C. SILLAR (Edinburgh) drew attention to a possiblecause in some cases of oedema being the absorption of toxicsubstances from the intestine. The advantage gained byclearing the intestine, the efficacy of fasting and a low diet,and the rapid absorption of calomel in some cases from theintestine gave additional proof that at times the condition Iwas caused by absorption of toxic products from the intes-tine, and in treatment this possible cause must not be over-looked. :
The PRESIDENT, replying in the absence of Dr. Rolleston, 7said that it was very difficult to estimate the effect of treat- 1ment. Statistics were useless, for the pathological condi- itions were so varied. Cardiac oedema in its lesser forms was 1
so transitory and so easily relieved by rest that he could notthink that its occurrence in these cases bespoke any severecondition of toxaemia. He agreed with what Dr. Charterishad said that cedematous patients were intolerant ofmercury.
Dr. ROBERT MAY (Belfast) read a paper entitled’’ JZ7<6 Action of Cresotinie and Toluio Acids, with Notes on the
Treatment of Acute Rhe2cmatdsm with Orresotinio Acid." "
He referred to previous researches and pointed out that.former investigators had worked with impure acids. His-own experiments showed that cresotinic acid had an action,closely resembling that of salicylic acid, while toxic:symptoms were less readily produced.
Sir LAUDER BRUNTON said that the paper was inter-
esting as giving a new and possibly useful remedy inrheumatic fever. It was also a valuable contribution to the
relationship between chemical constitution and physiologicalaction.
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ANATOMY AND PHYSIOLOGY.
THURSDAY, JULY 29TH.
President, Professor C. S. SHERRINGTON (Liverpool).A joint meeting with the Section of Obstetrics was held
in the Physiology class-room.Dr. A. LouisE McILROY (Glasgow) gave a demonstration
on the
Development of the Epfitheliccl Elements of the Ovary.Dr. McIlroy referred to information yielded by materialfrom the pig, the dog, the rabbit, the cat, and the humansubject, the material having been obtained from the ovariesof embryos and very young animals. Photographs of micro-scopic sections and diagrams illustrating the developmentalchanges were shown as lantern pictures. It was pointed outthat both ova and follicle cells were derived from germ cells.The changes undergone by the ova as they passed from thesurface of the ovary to its depths, including changes in thearrangements of the chromatin masses in filaments, &c.,were described and shown. So, too, the gradual investmentof the ova by follicle cells to form young Graafian follicleswas shown. Dr. McIlroy in different sections had foundcollections of cells which seemed to be examples of Pfiuge’stubules. These proved to be groups of follicle cells sur-rounding clear spaces from which ova had dropped out.
Dr. DAVID WATERSTON (Edinburgh) recommended theovary of the adult cat for study, because this yieldedexamples of all stages of change. He had investigated thesubject with respect to the origin of the zona pellucida. He
regarded this as probably derived from a filamentous mesh-work in the periphery of the ovum, formed by delicatebranching processes of the surrounding " nurse " cells whichwere metamorphosed follicle cells.The PRESIDENT in opening a discussion on the
Funotion and Distrribution of the Deep Afferrents,referred to the slightness of our knowledge of the subject.He said that the old classification of afferent nerves was (1)visceral and (2) somatic. Of somatic afferents those fromthe skin were fairly well known in their relations to the
economy of the body. Others were only obscurely known.Moreover, of visceral afferents many were surface afferents inorigin, but subsequently came to be placed deep in the body.With regard to the different kinds of stimuli to which afferentsresponded and their effects, it might be observed that conscioussensation was experienced on the surface of the body exposedto the ordinary agencies of the outer world. In the mouth-a zone intermediate between the last and the followingregion-the stimuli ordinarily perceived were not only thoseof ordinary sensation, but also those of taste and smell. Inthe alimentary canal beyond the mouth conscious sensationnormally ceased. Any sensations " felt " there, such as oftemperature and of pain, were only evoked by unusuallysevere stimuli. Here the afferents serve another purpose : -,by responding to chemical stimuli they, by reflex action,affect digestion-e.g., by promoting the secretion of gastricjuice. Again, stimuli arising in the alimentary canal andaffecting the afferent nerves there can evoke peristalsis.Langley’s experiments showed that this did not depend onthe sympathetic ganglia, for a loop of bowel entirely isolatedfrom these still manifested peristalsis. The same effectwas shown as regards the central nervous system. Here
