st. john's hospital dermatological society

1
21 MEDICAL SOCIETIES . ST. JOHN’S HOSPITAL DERMATOLOGICAL SOCIETY ON June 22nd, Prof. Charles Flandin delivered the Prosser White oration at 1, Wimpole-street, W., with Dr. W. N. Goldsmith, the president, in the chair. The subject of the address was Recent Advances in Leprosy with special reference to the methods adopted for dealing with the problem in France. Prof. Flandin thought that the time was ripe to bring before British dermatologists the present position of leprosy, as summed up at the recent congress of the International Leprosy Association held at Cairo, and to draw their attention to conditions in France, which might have considerable interest for this country. The recorded amount of leprosy in any country depended very largely on the effort expended in ascertainment, but there were certain disquieting features in the present situation in Europe which might lead to a reconsideration of our attitude to the whole problem. Although it was almost a law that leprosy declines as social and hygienic standards rise and although the great leprologists of the last generation had declared that they had never or hardly ever come across leprosy of indigenous origin in Western Europe during the whole of their lives, yet Prof. Flandin had found in the short space of three years ten cases in Paris, none of which had ever left France. He referred to the discovery of indigenous cases in England by Dr. J. M. H. MacLeod and stated that in certain other European countries, notably Rumania, the disease was said to be greatly on the increase. In his clinic at the Hôpital Saint Louis he had been able to make some exact observations of the incubation period and had been surprised to find a certain number of cases in which that period was comparatively short. In soldiers, officials, and others who returned from countries in which leprosy was endemic the disease might appear at an interval of from six months to twenty years, but in some of the indigenous cases the incubation period was less than six months, in one case apparently as little as two months. Moreover he was convinced that the first objective sign of leprosy by no means denoted the beginning of infection. " Leprous fever," a continued fever with pains especially round the joints, was nearly always noted before the actual develop- ment of the lesions. Such persons had undoubtedly been infected and were in a state of allergy, as could be shown by a non-specific reaction following the injection of tuberculin. The intradermal injection of chaulmoogra oil would attract Hansen’s bacilli to the site of the injection and a definite diagnosis could be obtained by demonstrating them in it after about an eight-day interval. The site of election from which to obtain bacilli was undoubtedly the lobule of the ear. As to treatment, he had seen many methods come and go but he had considerable hopes of a colloidal preparation of cholesterol and chaulmoogra esters which was given intravenously daily in doses of about 10 to 15 c.cm. Treatment was recommenced at the first sign of a relapse, but he thought that it might be better to continue treatment after all signs had disappeared on the analogy of the arsenical compounds in the treatment of syphilis. Commenting on administrative methods, he expressed his conviction that the compulsory notifica- tion in force in France was useless. The leper would change his name and run the risk of prison rather than expose himself to the possibility of being shut up in a leprosarium. As in tuberculosis, the examination of family contacts was essential, but this was impossible through official machinery. The education of the public was perhaps the most important need. They must be taught that only prolonged and intimate contact as in family life was dangerous and that leprosy could be regarded as less contagious than tuberculosis and at least equally amenable to treat- ment. Meanwhile he pleaded for close coordination between the specialists of England and France interested in the subject in order that, first, some ascertainment of the real numbers might be made, and secondly that such action as might be needed should be the result of the experience of both countries pooled in a " front commun de la ]6pre." DEVON AND EXETER MEDICO- CHIRURGICAL SOCIETY AT a meeting of this society held on May 26th Dr. CRICHTON MACGAFFEY gave an address entitled Type Reactions of the Kidney to Disease The classification and nomenclature of renal disorders, he said, has been a source of controversy and perplexity ever since Bright’s disease was first described. Bright’s original description was itself confusing, in that it embraced more than one variety of kidney disease. Volhard and Farr in 1914 did much to clear the issue, and Van Slyke materially advanced our knowledge by the introduction of his urea-clearance test. Roper in 1926 laid stress on the changes that take place in the albumin content of the blood where there is much oedema. It is now possible to include all the varieties of renal disease under three type reactions-degenerative, hsemorrhagic, and hypertensive. The degenerative type includes all those cases in which albuminuria is the prominent feature, such as chronic parenchymatous nephritis or nephrosis. Although the tubules are sometimes severely damaged, there is reason to believe that the kidney is not the primary focus of disease. There is in fact a prerenal deviation of salt and water causing their retention with resultant cedema, and the albumin found in the urine comes, in the first instance, not from the kidney but from the blood stream. When albumin in the blood stream falls from the normal 4-3 per cent. to 2-7 per cent., oedema appears. Further proof of this prerenal deviation is afforded by experi- ment. For example, large draughts of normal saline do not cause diuresis ; egg albumin, intravenously injected, appears in the urine as such even when the kidneys are normal; intravenous saline causes diuresis, but not if an artificial acidosis is produced as a result of temporary ischaemia ; indeed all the symptoms of uraemia follow if the experiment is pushed to its limits. This explains the perplexing normal renal function often met with in nephrosis and also the fact that mercurial poisoning, which primarily affects the tubules, does not cause oedema until the glomeruli are damaged. The haemorrhagic type, both acute and chronic, is a true nephritis, in that the blood-cells in the urine denote active renal damage, the main brunt of the disease falling on the glomeruli. In the acute

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Page 1: ST. JOHN'S HOSPITAL DERMATOLOGICAL SOCIETY

21

MEDICAL SOCIETIES.

ST. JOHN’S HOSPITAL DERMATOLOGICAL

SOCIETY

ON June 22nd, Prof. Charles Flandin deliveredthe Prosser White oration at 1, Wimpole-street, W.,with Dr. W. N. Goldsmith, the president, in the chair.The subject of the address was

Recent Advances in Leprosywith special reference to the methods adopted fordealing with the problem in France.

Prof. Flandin thought that the time was ripe tobring before British dermatologists the presentposition of leprosy, as summed up at the recent congressof the International Leprosy Association held at

Cairo, and to draw their attention to conditions inFrance, which might have considerable interest forthis country. The recorded amount of leprosy in

any country depended very largely on the effort

expended in ascertainment, but there were certaindisquieting features in the present situation in Europewhich might lead to a reconsideration of our attitudeto the whole problem. Although it was almost alaw that leprosy declines as social and hygienicstandards rise and although the great leprologistsof the last generation had declared that they had neveror hardly ever come across leprosy of indigenousorigin in Western Europe during the whole of theirlives, yet Prof. Flandin had found in the short spaceof three years ten cases in Paris, none of which hadever left France. He referred to the discovery ofindigenous cases in England by Dr. J. M. H. MacLeodand stated that in certain other European countries,notably Rumania, the disease was said to be greatlyon the increase.

In his clinic at the Hôpital Saint Louis he hadbeen able to make some exact observations of theincubation period and had been surprised to find acertain number of cases in which that period wascomparatively short. In soldiers, officials, and otherswho returned from countries in which leprosy wasendemic the disease might appear at an interval offrom six months to twenty years, but in some of theindigenous cases the incubation period was less thansix months, in one case apparently as little as

two months. Moreover he was convinced that thefirst objective sign of leprosy by no means denotedthe beginning of infection. " Leprous fever," a

continued fever with pains especially round the joints,was nearly always noted before the actual develop-ment of the lesions. Such persons had undoubtedlybeen infected and were in a state of allergy, as couldbe shown by a non-specific reaction following the

injection of tuberculin. The intradermal injectionof chaulmoogra oil would attract Hansen’s bacillito the site of the injection and a definite diagnosiscould be obtained by demonstrating them in it afterabout an eight-day interval. The site of electionfrom which to obtain bacilli was undoubtedly thelobule of the ear.As to treatment, he had seen many methods come

and go but he had considerable hopes of a colloidalpreparation of cholesterol and chaulmoogra esterswhich was given intravenously daily in doses of about10 to 15 c.cm. Treatment was recommenced at thefirst sign of a relapse, but he thought that it mightbe better to continue treatment after all signs haddisappeared on the analogy of the arsenical compoundsin the treatment of syphilis.Commenting on administrative methods, he

expressed his conviction that the compulsory notifica-tion in force in France was useless. The leper wouldchange his name and run the risk of prison rather thanexpose himself to the possibility of being shut upin a leprosarium. As in tuberculosis, the examinationof family contacts was essential, but this was impossiblethrough official machinery. The education of thepublic was perhaps the most important need. Theymust be taught that only prolonged and intimatecontact as in family life was dangerous and thatleprosy could be regarded as less contagious thantuberculosis and at least equally amenable to treat-ment. Meanwhile he pleaded for close coordinationbetween the specialists of England and Franceinterested in the subject in order that, first, someascertainment of the real numbers might be made,and secondly that such action as might be neededshould be the result of the experience of bothcountries pooled in a " front commun de la ]6pre."

DEVON AND EXETER MEDICO-

CHIRURGICAL SOCIETY

AT a meeting of this society held on May 26thDr. CRICHTON MACGAFFEY gave an address entitled

Type Reactions of the Kidney to DiseaseThe classification and nomenclature of renal disorders,he said, has been a source of controversy and perplexityever since Bright’s disease was first described. Bright’soriginal description was itself confusing, in that itembraced more than one variety of kidney disease.Volhard and Farr in 1914 did much to clear the issue,and Van Slyke materially advanced our knowledgeby the introduction of his urea-clearance test. Roperin 1926 laid stress on the changes that take place in thealbumin content of the blood where there is muchoedema.

It is now possible to include all the varieties of renaldisease under three type reactions-degenerative,hsemorrhagic, and hypertensive.The degenerative type includes all those cases in

which albuminuria is the prominent feature, such aschronic parenchymatous nephritis or nephrosis.Although the tubules are sometimes severely damaged,there is reason to believe that the kidney is not theprimary focus of disease. There is in fact a prerenaldeviation of salt and water causing their retentionwith resultant cedema, and the albumin found in theurine comes, in the first instance, not from the

kidney but from the blood stream. When albumin inthe blood stream falls from the normal 4-3 percent. to 2-7 per cent., oedema appears. Further

proof of this prerenal deviation is afforded by experi-ment. For example, large draughts of normal salinedo not cause diuresis ; egg albumin, intravenouslyinjected, appears in the urine as such even when thekidneys are normal; intravenous saline causes

diuresis, but not if an artificial acidosis is producedas a result of temporary ischaemia ; indeed all the

symptoms of uraemia follow if the experiment is

pushed to its limits. This explains the perplexingnormal renal function often met with in nephrosisand also the fact that mercurial poisoning, whichprimarily affects the tubules, does not cause oedemauntil the glomeruli are damaged.The haemorrhagic type, both acute and chronic,

is a true nephritis, in that the blood-cells in theurine denote active renal damage, the main brunt ofthe disease falling on the glomeruli. In the acute