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form with acute circulatory collapse, hissing dyspnoea,and engorged, pulsating cervical veins. Intravenousvitamin Bl (10-50 mg. of aneurin daily) might begiven in such cases. More commonly the onset wasinsidious and the course chronic, and 5-10 mg.subcutaneously or by mouth would be sufficient.The diagnosis rested on the dietetic history, theassociated polyneuritis, the demonstration of reducedvitamin Bl in blood and urine, and the dramaticeffects of giving the vitamin. The pyruvic acid inthe blood might also be demonstrated, and Aalsmeer’sadrenaline test was positive : the injection ofadrenaline into the blood enhanced the symptoms.Pitressin would reduce the cardiac manifestationsand constituted another test.Mr. H. G. UNGLEY described a case of beriberi

complicating pyloric stenosis. The effect of givingBl had been dramatic : the oedema had disappearedand the weight had fallen. Appetite had increasedand calf tenderness disappeared. The arterial soundshad no longer been audible without the pressure ofa cuff, and later the knee- and ankle-jerks hadreturned. It had been some time before the patienthad shown appreciable amounts of Bl in the bloodand urine. The electrocardiogram showed right axis-deviation and an upward rise of the R-T part, witha falling R-T in lead III. The adrenaline test causeda drop of diastolic pressure to zero. Another patienthad developed polyneuritis after a faulty gastro-enterostomy with gross stasis.

Dr. LucY WILLS said that the achlorhydria of

hyperthyroidism might be due to Bl deficiency :she had not been able to cure it before operation bygiving B1, but this might be due to inadequate dosage.Animals deprived of Bl showed neurological symptoms,even if given large quantities of Bl’ It was importantto remember the B2 complex neurological syndrome.

Dr. G. L. KoNSTAM spoke of two cases examinedradiologically before and after treatment with Bland showed the diminution in the transverse diameterof the heart and the improvement in the lung fields.Mr. A. L. BACHARACH thought that beer might

contain appreciable quantities of B1; this mightaccount for the rarity of alcoholic polyneuritis in thiscountry. The requirement of the normal person forhealth was about 2 mg. daily. A dose of less than thiswas hardly likely to produce effects in long-standingdeficiency.

Dr. GooDHART said that in America the

changes in beriberi heart disease presented variouspictures. Right-sided dilatation was not necessaryfor the diagnosis. Doses given in treatment wereoften much too small ; at least four times themaintenance requirement was necessary. The thera-peutic dose should never be less than 5 mg. daily,and doses of 60 mg. were quite rational. Pellagrawas frequent in alcohol addicts and was no longerconsidered to be a different disease in them from theendemic form. Patients often had more than onedeficiency. The peripheral neuritis of pellagra didnot respond to B but did respond to B1 ; it oughttherefore to be removed from the list of pellagrasymptoms. The skin lesions depended on environ-mental factors. The essential symptom of pellagrawas mucous membrane lesion, such as stomatitis.The mental symptoms were of several types : gradualdeterioration, encephalopathy, and Korsakoff’s syn-drome. If the encephalopathy could not be cured,the pellagra could not be cured. The action ofnicotinic acid had yet to be proved to be a directone ; the improvement in the encephalopathy mightbe secondary to the improvement in mucous

membranes. No one deficiency was likely to occuralone in human beings ; blunderbuss vitamin therapywas quite rational. The dose of nicotinic acid forpellagra was 100 mg. or more daily.

LIVERPOOL MEDICAL INSTITUTION

A MEETING of this institution was held on Dec. 15,1938, with Dr. E. GILBERT BARK, the president,in the chair.

Blood Tests in Cancer

Mr. M. M. DATNOW said that of the many serologicaltests devised in the hope of facilitating earlier

diagnosis in cancer none had proved specific andsome were not even accurate. Although the Vernestest was quite useful in following the course of casesunder various forms of treatment, the results weresometimes hard to interpret and not all the claimsof Vernes could be substantiated. Research hadtherefore been started with the idea of extractingfrom the serum the substance that gives the floccula-tion test. By simple extraction with acetone andether, Dr. J. N. Parrington had obtained a pastille,and the solution obtained on dissolving this indistilled water was found to give constant and reliableresults, comparing very favourably with those ofthe Vernes test. Mr. Datnow gave examples of thefigures obtained in various conditions.

Dr. G. E. 0. WILLIAMS pointed out that both withthe Vernes and the pastille tests sarcomas gave lowreadings and carcinomas high readings. In Mr.Datnow’s series a melanoma gave the highest readingof all.

Dr. ARTHUR GEMMELL thought that the results ofthe Vernes test in malignant disease ran parallel withthose he had obtained with the Bendien test. He

thought that the latter definitely foreshadowed therecurrence of malignant trouble after treatment,even before any physical signs of recurrence appeared.

Dr. CRONIN LowE said that both the Vernes and thecolloidal vanadium (Bendien) reaction depended ona complex of protein, lipoid, and inorganic plasmaconstituents. The variations had proved usefulnot only in diagnosis but (even more) in observationof progress under treatment. His own experiencecovered more than 3000 examinations, and referredto over 1600 cases, and though the results had notyet been tabulated, he had the impression that ifa serum reaction remained positive after local excisionor radiotherapy it meant that recurrence had occurredor was very probable ; whereas if it became less positiveor actually negative, recurrence had not so far takenplace. In cases with recurrence, after negative findings,the serum reaction had previously become positive.

Dr. ROBERT KEMP said it had been shown that theVernes, the Bendien, and the erythrocyte-sedimenta-tion tests give closely parallel results in the samepatient. All these serum tests were as yet quitenon-specific. The readings were abnormal not onlyin cancer but in pregnancy and menstruation, intuberculosis and syphilis, in all chronic and acuteinfections, and in many other conditions. Thereaction depended on tissue change or damage and ingeneral the result of the test varied with the extentof the lesion. There was so far no evidence that anyof these tests could distinguish cancer from theseother tissue reactions. It had, however, alwaysbeen conceded that the Vernes and similar testsreflected the variation in activity of such a lesionas a malignant growth.

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Pancreatic Extract in Graves’s Disease

Dr. C. BAIRD MACDONALD read a paper on thetreatment of exophthalmic goitre with pancreaticextract. Seven years’ experience had, he said,convinced him that this remedy deserved a trial

especially in early cases. The treatment had a

rational basis, for in thyroid disease there was oftenconsiderable disturbance in the digestive system,with such symptoms as diarrhoea, very light-colouredstools, increased appetite and thirst. These symptomswere usually attributed to increased activity ofthe sympathetic nervous system, but they were morelikely to be due to pancreatic insufficiency. Inalmost every case of Graves’s disease there was some

carbohydrate intolerance, and spontaneous glycosuriawas often seen. Hyperthyroidism aggravated diabetesmellitus ; thyroidectomy ameliorated it. The symp-toms of toxic goitre disappeared after drainage ofthe gall-bladder in cases where there were fattystools and other signs of pancreatic disease. Loewi’stest was positive only in cases of pancreatitis andthyrotoxicosis.The increased metabolism in Graves’s disease

demanded a liberal supply of fats and starches in thediet, and the oral administration of pancreatic extractmust help the pancreas to break down and absorbthis increased amount and thereby obtain iodine inits most assimilable form. The treatment Dr.Macdonald recommended was to give Palatinoidspancreatin grains 5 thrice daily before food, combinedwith Pulverettes alphidine (Oppenheimer) twicedaily between meals every second or third day.Lugol’s iodine minims 3 or 4 might be used insteadof the alphidine. Patients should carry on if at allpossible with their usual duties so as to help themental outlook. The treatment might be successfulin a few months but regular treatment had not beencarried out for more than three years in any of thecases treated. Exophthalmos or goitre had veryseldom increased or even developed with systematictreatment in the incipient cases.

Since 1931 the speaker had treated 42 cases oftoxic goitre of varying degrees and types : there hadbeen 21 cures and 17 were still undergoing treatment.In 3 cases the patient had died but 2 of these hadsuffered from the condition for eighteen years andthe other had a thyroid of the large toxic adenomatoustype. Of the 17 cases now under treatment allwere reacting well except 1 in which there was neitherpersonal nor environmental cooperation.

Dr. R. J. MINNITT said he had been associated with3 cases in which this treatment had been given.They were of the incipient type. One had shownmelancholic symptoms, and after a year’s treatmentcould be looked upon as cured. The second was

subject to thyrotoxic crises, and had been very muchimproved. In the third case the treatment hadbeen discontinued.

Mr. PHILIP HAWE said that cases of thyrotoxicosisfall into three groups: (1) mild with fluctuation;(2) chronic with or without complications; (3)fulminating. It was clear that Dr. Macdonalddid not include the fulminating cases or the chroniccases with complications as suitable for more thana short trial of his treatment. The remaining groupsincluded those cases which no surgeon is anxiousto operate on, although failure of non-surgical treat-ment might necessitate operation. It was of thegreatest importance that cases medically treatedshould not be allowed to lapse into the stage ofserious complications. With this proviso Dr.Macdonald’s treatment should be given an extensivetrial, for it appeared to offer relief in cases where

operation seemed unnecessarily drastic, includingespecially the early mild cases.

Dr. A. E. HODGSON said that one of Dr. Macdonald’spatients, a girl of 18, whilst under treatment withpancreatin, had come through his hands as a diph-theria carrier. Her tonsils had been removed bydissection, with no cardiac or other difficulty whatever.

Mr. J. B. OLDHAM said that the surgical treatmentof thyrotoxicosis was an admission of failure whichwas only justified by its good results. He con-

gratulated Dr. Macdonald on the successes he hadobtained, but doubted if the cases he had had wereof the same type or severity as those thatftt presentcame to the surgeon. A high proportion of Dr.Macdonald’s successful cases appeared to have hadalimentary symptoms ; in these cases Mr. Oldhamagreed that treatment with pancreatin producedconsiderable improvement and he often used it inpreparing patients for operation. He (Mr. Oldham),however, had not been fortunate enough to cure anypatient with Dr. Macdonald’s methods. He alsodoubted the diagnosis in one of the cases Dr. Macdonaldhad presented. The patient had a normal pulse-rate but showed some tremor of the fingers, and thediagnosis had been made on the result of the

impedance-angle test. Mr. Oldham had had a largeexperience of the test and was convinced that it wasvalueless.

ROYAL ACADEMY OF MEDICINE IN

IRELAND

A MEETING of the section of pathology was heldon Nov. 9, 1938, with Dr. R. A. Q. O’MEARA, thepresident, in the chair.

An Organism Simulating Diphtheria BacillusDr. W. HAYES, in demonstrating Corynebacterium

ovis isolated from the throat of a suspected diphtheriacarrier, began by describing the method by whichcarriers were identified. A throat-swab was takenand rubbed on the surface of a potassium telluriteplate or slope. If after 48 hours’ incubation it wasfound that suggestive black colonies had grown, oneof these colonies was subcultured on a serum slopeand afterwards filmed. Then if morphologicallycharacteristic diphtheria bacilli were seen a salinesuspension of the serum slope was injected into aguinea-pig. If the animal died within five days andshowed characteristic post-mortem changes-the mostimportant and constant of which was congestion ofthe suprarenal glands-the pathologist would reportvirulent diphtheria bacilli present. In the presentcase an organism had been isolated which fulfilledall these conditions except that it did not producesuprarenal congestion in the guinea-pig. It camefrom the throat of a healthy nurse, suspected of beinga diphtheria carrier, and its fermentation reactionswere identical with those of the diphtheria bacillus,glucose being fermented but not saccharose. It

rapidly killed a guinea-pig that had been passivelyimmunised with diphtheria antitoxin, and it was

evidently a corynebacterium producing a powerfulexotoxin distinct from diphtheria toxin. Besides

Corynebacterium diphtheriae, only two other exotoxin-producers of this genus were known-C. pseudotuber-culosis ovis and C. pseudotuberculosis murium. Thelatter was pathogenic for mice only and fermentedsaccharose, and it could therefore be deduced thatthe organism under discussion was C. ovis. It differedfrom C. diphtheriae in liquefying gelatin slowly, andagain unlike the diphtheria bacillus it had been