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The Bristol
m edico-chirurgical jo urn al
Bristol Medico-Chirurgical Society
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THE BRISTOL
A JOURNAL OF THE MEDfCAL SCIENCES FOR THE
WEST OF ENGLAND AND SOUTH WALES
PUBLISHED UNDER THE AUSPICES OF
THE BRISTOL MEDICO-CHIRURGICAL SOCIETY.
EDITOR :
R. SHINGLETON SMITH, M.D., B.Sc,
WITH WHOM ARK ASSOCIATED
J. MICHELL CLARKE. M.A.. M.D.. J. LACY FIRTH, M.S., M.D.,
AND JAMES SWAIN. M.S.. M.D
ASSISTANT-EDITOR :
P. WATSON WILLIAMS, M.D.
EDITORIAL secretary:
JAMES TAYLOR
"Scire C0t nescire, ntei to mc
Scire alius eciret/'
VOL. XXV.
BRISTOL: J. W. ARROWSMITH.
London : J. & A. Churchill, 7 Great Marlborough Stpekt.
1907,
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CATALOGUED
APR 18 1908
E. H, B.
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»4
CONTENTS OF VOLUME XXV.
Page
Prognosis. By P. H. Pye-Smith, M.D., F.R.C.P., F.R.S I
Cerebro-Spinal Fever (Epidemic Cerebro-Spinal Meningitis). By
D. S. Davies, M.D. Lond., and I. Walker Hall, M.D. Vict. . . 14
Operations for Deflections and Spurs of the Nasal Septum, with
special reference to Sub-mucous Resection. By Patrick
Watson Williams, M.D. Lond. . . . . . . . . 21
Two Cases of Ruptured Intestine. By Harold F. Mole, F.R.C.S. 38
Concluding Notes on a Case of Splenomegalic Cirrhosis in a Child
aged seven years. By Edward Cecil Williams, M.B.Cantab.
With post-mortem notes by J. M. Fortescue-Brickdale,
M.A., M.D. Oxon 43
Acquired Angioma of the Liver.
By A. Lewin Sheppard, M.B., B.S. Durh. .. . . . . 46
The Sanatorium Treatment of Pulmonary Tuberculosis — Is it a
Success ? By D. J. Chowry Muthu, M.D. . . . . . . 50
Some Notes on Styracol. By Charles, Reinhardt, M.D. . . . . 54
Obituary Notice —
Edward Markham Skerritt, M.D. Lond., F.R.C.P. . . 97
Cases Illustrating the More Unusual Complications of Pneumonia.
By J. MiCHELL Clarke, M.A., M.D. Cantab., F.R.C.P. . . 108
The Value of Compression of the Aorta in the Treatment of Post-
partum Hemorrhage. By F. Percy Elliott, M.B. Aberd. 121, 310
Eighty Cases of Lupus Vulgaris.
By W. Kenneth Wills, M.D. Cantab. . . . . . . 127
A Case of Narcolepsy. By Bertram M. H. Rogers, M.D. Oxon. . . 144
Tumours and Tubercle in Monkeys.
By W. Roger Williams, F.R.C.S 149
Rheumatic Carditis in Childhood. By Carey Coombs, M.D. Lond. 193
Treatment of Graves's Disease by Anti-Thyreoid Serum and by
X-Rays. By J. Michell Clarke, M.A., M.D.Cantab., F.R.C.P. 201
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CONTENTS.
Page
Cerebral Lesions in Pregnancy and Parturition. By Walter C.
SwAYNE, M.D., B.S. Lond 209
A Suggested Treatment for Functional Aphonia. By C. Percival
Crouch, M.B. Lond., F.R.C.S 214
A Case of Filariasis : Removal of Lymphatic Varix by Operation.
By J. Paul Bush, C.M.G., and J. A. Nixon, M.B. Cantab.,
M.R.C.P ' .. 218
The Medical Reading Society, Bristol. By L. M. Griffiths . . 222
Syphilis. By Henry Waldo, M.D. . . . . . . . . . . 289
Some Remarks on Spinal Anaesthesia as based upon the Personal
Observation of Thirty Cases. By Ernest W. Hey Groves,
M.S. Lond., F.R.C.S 305
The Value of Compression of the Aorta in the Treatment of Post-
partum Hemorrhage (continued). By F. Percy Elliott, M.B. 310
A Case of Generalised Sarcoma, with Blood Changes. By F. G.
Bushnell, M.D. . . . . . . . . . . . . . . 321
Proportional Representation and the Comparison of Radiographs.
By William Cotton, M.A., M.D., D.P.H.
Public Health in Bristol. 1906-7. By D. S. Davies, M.D. . .
Progress of the Medical Sciences
Reviews of Books
Editorial Notes
Notes on Preparations for the^Sick
The Library of the Bristol Medico-Chir
urgical Society . .
Meetings of Societies
Obituary Notices
Local Medical Notes
• •
••
••
326
s, M.D...
••
zz^
57.
152,
236,
341
69,
168,
25^
353
76,
177.
272,
368
83,
180,
278,
374
85.
182,
283,
379
87.
185.
28s,
382
••
90,
97
93.
187.
287,
383
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nDebtcos^Cbtrurgtcal JournaL
"Scire est nescire, nisi id me
Scire alius sciret.**
MARCH, 1907.
PROGNOSIS.^
BY
P. H. Pye-Smith, M.D., F.R.C.P., F.R.S.,
Consulting Physician to Guy's Hospital,
Prognosis is one of the most ancient branches of medicine. In
early times pathology, or the science of disease, did not exist, and
treatment was for the most part ineffectual as well as superstitious.
But the forecasting of events, when based upon prolonged ex-
perience, justly impresses both the educated and the vulgar. We
see this in the case of the oldest of sciences — ^astronomy, based
on observations and proved by the power of prediction of
eclipses. One can imagine how those who had scoffed at a mortal
being able to foretell the overshadowing of the sun or moon, and
to foretell it on a definite day or night, must have been impressed
by the beginning and completion of the shadow of the earth.
The same holds with other branches of science : the cultivation
of crops and of flowers, construction of piers and bridges, the
^ An address given to the meeting of the Bristol Medico-Chirurgical
Society on February 13 th, 1907.
2
Vol. XXV. No. 95.
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2 DR. P. H. PYE-SMITH
power of transmitting messages by the electric telegraph, and
the still more marvellous achievement of wireless telegraphy.
Incredible as these discoveries once were they are no longer so,,
even when the explanation of the how and the why is incomplete.
So when a child is attacked by the s5miptoms of pyrexia it is
a wonderful thing that we can foretell the progress of the disease,,
its gradual evolution, and, when the crisis is passed, its gradual
return to the conditions of health. Nothing is more solid as a
foundation for rational medicine than the power we have of fore-
telling within tolerably narrow limits the course of such diseases
as S5^hilis, variola, and enteric fever. No justification can be
more complete, no demonstration stronger to every candid
observer, than the accomplishment of a prediction of a disease.
The following are a few examples from the prognosis of the
father of medicine : —
He taught that when delirium disappears after the patient
has slept he is likely to recover. That it is a bad sign for the
convalescent to regain his appetite without putting on flesh. In
cases of jaundice, if the liver becomes hard to the touch the
prognosis is grave. When spitting of blood is followed by expec-
toration of matter the prognosis is unfavourable. When an
abscess is opened by the knife or the cautery, if pure white matter
flows out the patient will do well, but if it be mixed with blood
and is foul in odour he will probably not recover. In acute
diseases prognostics either of death or recovery are more uncertain
than in those of a chronic course.
During the long retrogression which followed the Hippocratic
era, when Galen taught sinatomy on monkeys and hogs, and
treatment was empirical and usually inefficient, the shrewdness
and unbiased observations of the best physicians enabled them
to form a prognosis, sometimes with remarkable success.
Again, next to immediate relief of pain there is no question
so paramount with the patient himself as that of the event.
What is it ? generally means. What will it do to me ? A favour-
able prognosis when given with authority is often more important
than any method of treatment, and while we must never give
patients hopes which cannot be fulfilled, we must preserve the
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ON PROGNOSIS. 3
priceless benefit of that determination to get well, of that interest
in one's own case, which is one of the chief aids to recovery. The
mere statement of the name of some obscure condition, and still
more the prediction of recovery, however guarded as being
probable rather than certain, will often ensure sleep in a despon-
dent patient, and will rouse the effort which is needful for recovery.
The diseases of children afford very interesting examples of
prognosis. In early childhood the patient can give us little or
no account of his condition, and we have to depend entirely
upon our own observation. Nothing, therefore, is better exercise
for beginners than to investigate one of the exanthems or a severe
injury in a Httle child. If they cannot help us by information
tl^ey at least cannot set us on the wrong track (as adults frequently
do), sometimes by wilful deception, but more often by the in-
curable mixing-up of facts and inferences and the obstinate refusal
to tell us what no one else can — the patient's own feeling, and not
a mixture of information from others, in supposed agreement with
the theory of medicine.
In early hfe the processes of disease are very rapid, and a
child may speedily be brought from the condition of blooming
health to that of grave sickness, or even of imminent danger.
But although this is true, particularly of diarrhoea and laryngitis,
it is also true that children have a great power of resistance to a
malady, so that his recuperative power not infrequently carries
a child safely through extreme peril. Anatomical conditions of
the child's body render the prognosis of invagination and laryn-
geal diphtheria pecuHarly fatal ; but diphtheria in children has
been happily robbed of its terrors by the scientific treatment that
has enabled us to meet the case with hope, and usually with
success, which in patients under three years old was almost certain
to end fatally.
When we deal with a disease of known pathology prognosis is
comparatively easy. Cancer and hydrophobia, glanders and
leprosy are soon recognised, and their diagnosis involves the
gravity of the forecast. As soon as we have made the diagnosis
of modified variola or of enteric fever we can predict the course
of the disease and the order of its symptoms. When we have
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4 DR. P, H. PYE-SMITH
decided that a supposed scarlatina rash is a local erythema, or a
scaly patch on the scalp is not ringworm, the prognosis carries
with it the means of cure. Some of our elements of prognosis
depend on the patient himself rather than on the disease. Certain
symptoms, Hke hyperpyrexia, subsultus tendinum, or convul-
sions at once suggest a grave prognosis ; . while, on the other hand,
to see a patient's appetite returning, to observe his lying on his
side instead of on his back, the diminished temperature and less
frequent pulse, a recovery of strength and volume in the voice,
are signs of improvement which we all recognise as guiding our
prognosis.
Although their frame is fragile, we must all of us have been
struck by the power of resistance of children in spite of loss of flesh,
how they will rally after extreme emaciation or continued con-
vulsions, or prolonged bronchitis. Even the worst forms of
eczema are very seldom fatal. Children will struggle through
rickets and will surmount the successive invasions of whooping-
cough and bronchitis, of measles and diphtheria, scarlet fever and
nephritis. Never give up a child till he is screwed down.
With older children, after the first dentition and until puberty
is attained, the prognosis is much more favourable than in young
children, and even in adults. Children between two and twelve
are still subject to acute and severe illness, and may rapidly pass
in a few hours from apparent health to imminent danger, but,
compared with infants, their circulation is more stable, their
vigour in breathing and coughing is much greater, and their
power of maintaining temperature more perfect.
The older the patient attacked by diphtheria or scarlatina or
ringworm the better is the prognosis. In one well-marked and
severe disease — ^lobar pneumonia^ — ^we must all have been struck
by the wonderful power of recovery shown by children of between
three and fifteen. We may say that death from uncomplicated
acute pneumonia at this age is almost unknown. The same is
true of enteric fever, the mildest forms of which are characteristic
of this early age.
In this period, however, the prognosis of phthisis is very grave,
^ Not "croupous pneumonia."
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ON PROGNOSIS. 5
and it is often complicated by general disseminated tubercle^
Scarlatina is more severe in these young subjects than in adult
life, while measles is less so, and rubella is less severe and more
safe at an older age.
There remains one of the most striking differences between
the prognosis of a child and an adult — I mean diabetes. Happily
rare in children and young adults, its danger is almost exactly
measured by the age of the patient. The rare cases which occur
in infants are probably always fatal, and the S5nnptoms are very
acute. In young adults it is still a very grave and menacing
disease, and it is not till after forty that the cases become milder,
less sudden in onset, and less severe in their symptoms, while, as
we all know, diabetes in patients of advanced years is sometimes
so mild that it is scarcely more than a bearable infirmity.
The period from twenty-five to fifty is probably on the whole
the most favourable for diseases, acute or chronic. Cases of
unvaccinated small-pox, if they recover at all, belong to early life,
ten to twenty. During the period of forty to sixty, cases of
phthisis are generally more chronic and more amenable to treat-
ment than before. The muscular powers and the vigour of the
heart, the respiration, and the brain are in most persons still at
their best. When those who have attained an older period of life
may still show remarkable mental ability, their enduring power
is in almost all cases much diminished. The old man who would
guard his laurels must speak but seldom. On the other hand,
old people are less plagued with the sick headaches, indigestion,
and eczema of early life. They are more Hable to cancer, particu-
larly of the stomach and rectum, but, according to the experience
of most of us, less so to sarcoma. As old age advsinces, it is re-
markable how many men and women retain considerable powers
of endurance. Many old men bear short sleep and diminished
rations better than they did in the prime of life, and are some-
times less fatigued than those twenty years younger by a day's
shooting on a warm September day or a night in a railway carriage.
Specific fevers are very fatal in old age. At the same time acute
pneumonia, though never the almost innocuous disease of youth,
is far from always fatal. I imagine the not infrequent cases I
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6 DR, P. H. PYE-SMITH
have seen of men and women of sixty-five, or even seventy, who
recovered from pneumonia, must be explained by their being
picked lives, that is to say, that they have surmounted so many
assaults in their long life that they are no longer ready to surrender
at the first summons. Cancer is, as we all know, not infrequent
in even the oldest, but it is in them that it is most often discovered
for the first time after death. Very chronic cases of cardiac
disease or Bright's disease are common in old age, but their
symptoms are less severe than in younger patients.^ In advanced
old age, apart from these almost latent organic lesions, the chief
mortality, like that of young children, is due to bronchitis or
diarrhoea. Cerebral hemorrhage, though common in old age, is
less so than at sixty ; but we must remember in these, as in other
cases, there are fewer persons living over seventy to furnish large
numbers of any disease. In old people arterial disease is almost
part of their natural condition, and probably there are few over
fifty but have some loss of elasticity of their arterial coats. Hence
the frequency of death in the aged, either from rupture of arteries
in the brain or, still more suddenly, from syncope of the heart.
Lastly, I would urge the conviction that old age is not in itself
a cause of death at all, however readily returns are made to the
Registrar-General. I do not remember seeing a post-mortem
examination in which there was not present degenerated blood-
vessels, or renal disease, bronchitis, or diarrhoea, latent cancer,
or some other obvious anatomical lesion.
Here let me urge the importance of drawing up the certificate
of death either in accordance with an autopsy, or, when this cannot
be obtained, in accordance with the symptoms during life. Apo-
plexy is a condition we can all recognise, and death from that
cause is scientifically certain. But if we return *' cerebral hemorr-
hage" as the cause of death, we are putting a probable conclusion
only, and the result is that common diseases are made more
common and rare diseases more rare than they truly are. Again
and again I have seen such causes of death as anterior polio-
myelitis, cancer of the pancreas, or tumour of the lung reported
1 Mental and moral mellowing of old age —
" The soul's dark cottage, battered and decayed,
Lets in new light thro' chinks that time has made."
Digitized by VjOOQIC
ON PROGNOSIS. 7
•without any anatomical evidence. " Congestion " of the lungs
or liver or other organs is another source of false facts. If active,
the hyperaemia is only part of a local inflammation ; if passive,
it is due to some other primary cause. No doubt the double
return asked for invites such secondary causes of death, but we
are not obliged to make the double return, and a statement that
a patient died of pneumonia, of phthisis, of renal dropsy, or
of cancer of the liver is less, not more, valuable if bronchitis or
pleurisy are added, or if we return cancer of the stomach instead
of cancer of the liver, because we know that with few exceptions
hepatic cancer is secondary to that of the stomach or bowels.
The difference between the sexes in the incidence of disease is
much less than the difference of age. More girls than boys are
subjects of chorea and whooping-cough. The exanthems affect
both sexes equally. The frequency of scarlatina as a complication
of dehvery has long been recognised.
Speaking generally, better prognosis may be given in cases
of serious disease when the patient is a woman than when a man.
This applies strongly to gastric ulcer, and not to duodenal ; also to
valvular disease of the heart and to anaemia, but it certainly does
not apply to phthisis.
In the large group of nervous affections we may, as a rule, give
a better prognosis in the case of women. They more often recover
from what has the appearance and many of the symptoms of
organic disease : a cerebral hemorrhage, a tumour of the brain,
acute myehtis or sclerosis of the spinal cord.
An important point in forming a prognosis is the different
gravity of an acute attack occurring in a healthy organism and in
a patient already suffering from chronic disease. Acute pneu-
monia, acute bronchitis, and infective fevers are all more grave
in the case of patients already suffering from chronic disorders ;
and we may affirm that this is particularly true of diseases of the
kidneys, the heart, and the lungs. The presence of Bright's
•disease is an important element in prognosis, not only when com-
plicated by a new disorder, but when tried by injuries, including
surgical operations, and by drugs like opium and mercury.
Cardiac disease increases the mortality of bronchitis, of pulmonary
Digitized by VjOOQIC
8 DR.. P. H. PYE-SMITH
catarrh (so-called ** lobular pneumonia "), and acute lobar pneu-
monia. The presence of chronic phthisis and emphysema is most
important in cases of acute bronchitis, whereas I have seen
patients even at an advanced stage of phthisis go favourably
through an attack of scarlatina, enterica, and acute rheumatism.
Phthisis scarcely increases the danger of valvular disease. On
the contrary, when cardiac incompetence is established it often
appears to check the progress of consumption.
The presence of glycosuria has a marked deleterious effect on
the prognosis of injuries or surgical operations, and also upon-
cases of acute pneumonia.
AncBmia differs so much in its causes and pathology that it
is difficult to speak of its influence on prognosis generally. We
may say that anaemia caused by direct hemorrhage, by injury or
rupture of a blood-vessel, is less serious than when pallor appears
during convalescence from fever or rheumatism, or when caused
by privation or by deficiency of light and air.
The influence of malaria as an element of prognosis, like that
of syphilis, has probably been overrated. It is very doubtful
if syphilis is responsible for anything but its own direct effects ;
but we must include among the later effects of lues the chronic
nervous degenerations of the nervous centres which have
long been chnically recognised as general paralysis and tabes.
Another disease to which some writers attribute, I think,
far too extensive an influence, is gout, particularly when the
demonstrable anatomical effects are supplemented by various
other symptoms which lead to drinking weak mineral waters
and travelling to distant and expensive baths.
Prognosis of enteric fever depends, first, upon the age of the
patient. In children it is as a rule a recoverable disease. I
once saw a little boy pass through a severe attack in which
there was every evidence of perforation of the bowel except
seeing it, and he went out as healthy and much fatter than any
boy of his age I have seen.
Pneumonia, like others of the group, is more favourable
when primary, and less so when secondary to other diseases.
Many authorities, especially abroad, teach that syphilis, once
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ON PROGNOSIS. 9
acquired, is never got rid of, but therein I cannot agree. That
it is a disease which often continues and relapses after apparent
cure is a matter of common experience, but there are numerous
cases in which all symptoms disappeared, the colour again
became that of health, and the nourishment of the body as good
as ever.
The prognosis of phthisis used to be considered almost hope-
less, but at present it is generally recognised that the disease is
curable. For proof of this we have only to frequent the dead-
house of any large hospital to find in patients who have died
from accidental injury, or some entirely different disease, unmis-
takable evidence of old phthisis in thickening and adhesions
and contractions, so that the chnical course of the disease is
confirmed by the results of post-mortem anatomy. We must
all have seen such cases in practice, and noticed those who-
undoubtedly were affected in youth, living in health for many
years, and dying at last from some other malady. This result
is, however, far from constant. I have again and again observed
that a patient who showed signs of tuberculosis in early adult
life, after recovering and living for many years in health, may
again develop symptoms of the disease of his youth. Two
patients I have had for many years under observation in whom
this result followed, and I am inclined to believe that the ma-
jority of cases called senile phthisis are really a recrudescence of
a disease which was cured in early adult life.
The prognosis of cardiac disease. — In the early days of
physical diagnosis it seems to have been thought by some of
the leading physicians of the day that the presence of a murmur
indicated incurable disease, and with the oracular solemnity of
happily past times, an eminent physician, after listening to a
patient's heart, said, '* I am sorry to tell you, sir, that with the
aid of this stethoscope I have heard your death-knell." Now
valvular disease of the heart, regarded anatomically, is no doubt
incurable, yet consequent changes in the muscular walls of the
heart are sufficient to counteract the mischief done and to
restore the hydraulic equilibrium of the blood. We hear such
a process spoken of as an " effort of Nature " to deal with the
Digitized by VjOOQIC
TO DR. P. H. PYE-SMITH
disease. This is surely an inaccurate conception. There is no
such thing as conscious, or intelligent modification adapted to
cure a disease. The "effort of Nature" in causing contraction
of a serous ^surface sometimes remedies a dangerous lesion, but
as often these same adhesions may cause fatal strangulation.
The only healing power is the fact that any natural process,
when not too violently disturbed, tends to return to its previous
state of rest. The very processes which lead to a defence of the
organism in one case will lead to its destruction in another.
Even the phagocytes, which form such useful protection for an
organism, certainly are not acquainted with the object of their
life.
Passing now to the prognosis of Bright' s disease, we may
notice that an improved estimate of a patient's chances has
replaced, as in the case of phthisis and of cardiac disease, the
early estimates of its hopeless nature. The discoveries of
Laennec, Corrigan, and Stokes, like those of Bright, were re-
garded as pathologically interesting, but as affording little room
for • treatment. Acute nephritis is sometimes, indeed, so rapid
and severe — ^particularly in children — that bleeding, purging,
and hot baths are powerless to avert the fatal event ; but these
cases are rare, and the ordinary forms of tubal nephritis are
subacute in time and severity, and admit of ample time for
treatment. In the advanced stages of the granular kidney
treatment is much less efficacious ; but even then it is astonish-
ing how often a chronic case may be broken by gleams of hope,
and the final cause of death be due, not to uraemia, but to
cerebral hemorrhage.
In cases of ordinary cirrhosis of the liver, the organ is usually
in a state like that of the corresponding disease of the kidneys,
which depends upon a long course of toxic processes begun long
before they come under notice. Quite apart from their direct
effects, they probably cause still more numerous deaths when
they act in greatly aggravating the prognosis of pneiunonia or
other acute attack.
Tuberculous meningitis is, with reason, regarded as of the
worst possible prognosis, but I have seen it recover under the
Digitized by VjOOQIC
ON PROGNOSIS. II
influence of mercury in cases which seemed as certain in their
diagnosis as was possible without an autopsy.
Of the wonderful success in modem times of surgery in
<iiseases of the brain we are all proud, and all the more because
treatment is the result, not of chance good luck, but of carefully-
reasoned scientific facts, acquired in the only way that facts in
pathology can be discovered — ^by experiment on the lower
animals. The diagnosis of a tumour of the brain, its accurate
localisation and successful removal form, perhaps, the most brilliant
example of surgery at its best which the past century offered.
I remember an observation which the late Mr. Stocker, the
apothecary of Guy's Hospital in my student days, " obscurely
wise and roughly kind," used to make in going round the wards
to see urgent cases after the physician had gone home. *' If,''
said he, ** when you come with a candle to his bedside the patient
lies indifferent when you pull down the clothes and examine the
abdomen, that 's fever ; but if he pulls them up again and turns
•over on his side, and swears at you for disturbing him, that 's
brain."
The prognosis was often as sound as the diagnosis, but I am
afraid in this, as in so many other matters, ** the hits " — to use
Bacon's simile — *' are apt to be counted and the misses left out."
The best prognosis, like the best diagnosis, rests on the founda-
tion of observation and experience.
Of gout and of rheumatism it may be said that the arthritis
they have in common seldom, if ever, leads to a fatal result. It
is the rheumatic pyrexia which kills a patient with all the charac-
ters of a specific fever. On the other hand, gout has no such
affinities, but proves fatal indirectly by setting up disease of the
kidneys and the arteries. What our predecessors meant by gout
in the stomach we do not know. We merely recognise it as an
acute attack of flatulent dyspepsia, which can usually be cured
by soda and ether with other anti-spasmodics. I have observed
that the prognosis of rheumatic fever (provided that the heart
•escapes) is comparatively unaffected by anything but hyper-
pyrexia, and the joints seldom, and only after usually frequently-
repeated attacks, become deformed.
Digitized by VjOOQIC
12 DR. P. H. PYE-SMITH
Osteoarthritis, most unluckily still called rheumatic gout,
though so distressing a crippling disease, has no internal allies,
and is compatible with prolonged health for many years.
A fourth articular, disease, also confused with gout and
rheumatism, is gonorrhceal synovitis, remarkable by its origin,
its distribution, and its relation to the eye, where it sometimes
produces a subacute sclerotitis — quite distinct from infective
iritis, due to actual contact with the streptococci of a primary
focus — di true gonorrhceal ophthalmia. The prognosis of this
rather uncommon affection is that it never attacks the heart ;
that though often obstinate and prolonged, it never returns
whe.i once got rid of, unless a fresh attack of gonorrhoea
occurs, and then it almost always • recurs, as bad as before.
The prognosis of what used to be called typhlitis or peri-
typhlitis has changed remarkably in our lifetime. When de-
scribed by Addison in 1850, it was generally cured by starvation
or milk diet, opium, and local anodynes. The fatal cases were
very rare. Now the same disease — for it must be the same —
is often ushered in with great rapidity, and, unless early dealt
with by the surgeon, is apt to lead to death. While admitting
the frequency of such severe and rapid cases, I cannot throw
away the experience of earlier days when typhlitis was a com-
paratively frequent disease, usually cured without operation,
and only so treated when unusually severe or when the presence
of pus was early recognised.
The prognosis of renal disease varies with age and circum-
stances. In children it is happily rare, though far from innocent.
But in adults it is more manageable, and in old age a certain
amount of albuminuria is compatible with comfort, and seldom
ends in the rapid and profound coma seen in younger cases.
The prognosis of diabetes is better known now than it was
in the days of Prout. In those under adult age it is rapidly
and almost constantly fatal by coma. In early adult life it is a
still dangerous disease. In old age it is comparatively free from
danger.
Rational prognosis is the result of experience in cases, at the
bedside and in the dead-house. If every organ could be the
Digitized by VjOOQIC
ON PROGNOSIS. 13
seat of every kind of disorder we should never come to a con-
clusion ; but we know that each organ has its own more or less
restricted pathology, and therefore the path of accurate diagnosis
and successful prognosis lies through the dead-house. On its
portals might well be inscribed the sentence of our great master,
Harvey : "Ad viliorum animalium inspectionem . . . accedite ;
nam neque Dii desunt immortales maximusque omnipotens Pater
in minimis."
May I conclude, as I began, with a few aphorisms of
prognosis ?
Acute diseases following on chronic are the most dangerous.
A degree of pyrexia, which is unimportant in a child, is
serious in an adult.
Typhus is most dangerous in the case of elderly patients
and infants ; less so in young adults.
The most severe forms of scarlatina occur in children ; but
whooping-cough is dangerous only in young children.
Pneumonia is benign, as a rule, in children and young adults,
and is fatal in dnmkards.
Acute primary pleurisy is only dangerous when the pericar-
dium is also affected ; but the pleurisy secondary to tubercle, or
to cancer, or to Bright's disease is usually fatal.
(Edema of the glottis is seldom the cause of death ; oedema
of the Itmgs is often so.
*' Capillary bronchitis " is in most cases lobular catarrh.
Haemoptysis is seldom fatal by flooding the lungs. If it is,
the cause is probably a small aneurysm of the pulmonary artery.
Haematemesis is seldom directly fatal. Valvular lesions appear
to check rather than aggravate the progress of phthisis.
Sudden death is more often due to aortic incompetence than
to aortic obstruction, and more often due to mitral obstruction
than regurgitation.
Apoplexy, which is ingravescent, is almost always fatal.
Malignant growths are most rapidly fatal in children and
young adults. In old age they spread slowly, and sometimes
undergo more cr less complete wasting.
Digitized by VjOOQIC
CEREBRO-SPINAL FEVER (EPIDEMIC CEREBRO-SPINAL
MENINGITIS).
BY
D. S. Davies, M.D.,
Medical Officer of Health, Bristol,
AND
I. Walker Hall, M.D.,
Professor of Pathology, University College, Bristol;
Pathologist to the Bristol Royal Infirmary.
The invasion of New York by cerebro-spinal fever in the winter
and spring of 1904-5, when some 4,000 cases occurred,^ and
the more recent appearance of the disease in Glasgow (March,
1906), in Belfast, and some other districts, invite attention ta
its causation and prophylaxis.
It is generally recognised that a cerebro-spinal meningitis may
be set up by various causes, such as disease of the middle ear,,
pneumococcal, tubercular, or streptococcal infection, or as a
sequel to certain of the exanthemata ; but during the last years,,
the form (cerebro-spinal fever) which exhibits marked though
erratic infective properties under predisposing conditions at
present ill-understood, has been found to be definitely associated
with the organism of Weichselbaum, the diplococcus meningitidis
intracellularis.
The history oi the disease* is not without interest. Its occur-
rence is veiled before the nineteenth century, but in 1804-5
Vieusseaux, of Geneva, distinctly described it. In the following
year it appeared in America (Massachusetts), and the United
States have hardly been free from it since ; it became widely
spread during the Civil War. In Canada the outbreaks have
been small, probably owing to the scattered population. In
^ Flexner, Brit. M. J., 1906, ii. 1023.
' Bruce Low, Tr. Epidem. Soc. Lond., 1898-9, n.s., xviii. 53.
Digitized by VjOOQIC
CEROBROSPINAL FEVER. 15.
India it has been prevalent from time to time in the jails.
Europe has never been quite free since the Geneva outbreak,
in turn it spread to France, Italy and Denmark, and afterwards
to nearly every European country. In France it was noticed
that the outbreaks largely affected troops in garrison. A wide-
spread outbreak occurred in Dantzig in 1865-6, when 1,900
were attacked, chiefly children.
The disease was first noted in Ireland in 1845-6, when it
affected the Irish Constabulary and the workhouses at Dublin,
Bray, and Belfast '; again in 1866 it prevailed in the Dublin
barracks and in the Curragh ; in 1885-6-7 it again became
epidemic in Ireland. In the first six months of 1900 there was
an outbreak in Cork^ involving 100 cases and 25 deaths.
In Scotland it has been shown that, though not generally
recognised, the disease occurred from time to time in small
outbreaks between 1877 and 1886.
In England and Wales also various groups of cases have
from time to time been reported, but its nature appears to have
not infrequently escaped recognition ; it is probably not so rare
as is generally supposed, and since 1890 there has apparently
been a general tendency to ascribe obscure outbreaks to influenza.
Local History. — ^No widespread outbreak has been recorded in
the Bristol district, but Stack- has recorded an interesting group
of six cases received into the Royal Infirmary in 1900-1, in
five of which the diagnosis was confirmed by lumbar puncture
and recognition of the diplococcus intracellularis : the sixth case
occurred in the same house as, and was the daughter of, a fatal'
case. He sums up the most constant conditions as : (i) An
irregular temperature not assignable to other causes ; (2) pain in
the back of the head and neck ; (3) general hyperaesthesia ; (4)
herpes labiahs ; (5) Kernig's sign (inability to extend the leg on
the thigh when the thigh is at right angles to body) ; (6)
discovery of specific diplococcus.
The following table, for which we are indebted to Dr. A.
Rendle Short, gives a r6sum6 of cases which have been treatedl
in the Bristol Royal Infirmary since 1901 : —
^ Brit. M, J,, 1907, i. 461. ^ Bristol M.-Chir. J , 1901, xix. 44.
Digitized by VjOOQIC
i6
DR. D. S. DAVIES AND DR. I. WALKER HALL
DATS OP
ADMISSION. SEX. AGE.
SYMPTOMS, ETC.
8.2.02 F 22 Headache, optic neuritis, Cure..
vomiting, squint, no fever
2.6.02 F 14 Headache, coma, hazy Cure.,
discs, herpes, no fever
27.4.03 M 37 Coma, fever, delirium . . Death
5.3.04 M 15 Fever, delirium, headache Cure . .
retraction, herpes, hazy
discs
26.5.04 M 15 Fever, headache, herpes, Death
Kemig's sign
18.9.05 M 6/12 Posterior basic meningitis, Death
with retraction
31.12.05 M 33 Headache, fever, coma. Death
retraction
2.3.06 F 10 Proptosis, sphenoidal Death
sinusitis, basic meningitis
22.2.06 M 3/12 Posterior basic meningitis Death
with retraction
Perhaps not
proven
Doubtful
M. meningiti-
dis (in nose
also)
M.
meningitidis
M.
meningitidis
M.
meningitidis
Diplococci
and staphy-
lococci
Undoubtedly
a form of C.S,
meningitis
Proved at
autopsy
Infectivity, — ^The recorded facts in regard to cerebro-spinal
fever are not so contradictory as they at first appear to be, and
there is Httle doubt that the chief incidence of the disease is upon
childhood, or upon young adult life,* and that in close communi-
ties, such as barracks or institutions, the disease is certainly,
though apparently not very readily, communicable.
The seemingly sporadic habit of the disease, when introduced
under conditions of less intimate association, as into a village,
may be explained by the habits of the organism, which when
grown artificially is readily attenuated, and may thus, if similar
attenuation attend its natural distribution amongst individuals
of varying resistance, give rise to ill-marked cases, or to *' carrier "
cases, by which the infection is preserved and handed on, exactly
as in the case of diphtheria. Extensive investigations by
Osterman showed that the meningococcus was present in the
nasal cavities of 74 per cent, of the people who had been in the
neighbourhood of the patients. Jehle points out that miners
form specially good carriers, as the organism thrives best apart
from light, and in a warm, moist atmosphere.
1 Hirsch points out that the age limit in most epidemics is from i to 15,
but in "military" epidemics the most vulnerable ages are from 18 to 24.
— Geographical and Historical Pathology, vol. iii.. New Sydenham Soc., 1886
Digitized by VjOOQIC
ON CEREBRO-SPINAL FEVER. VJ
It must not be forgotten that animals may also act as carriers.
In the 1872 New York outbreak, and in the 1866 Irish outbreak,
horses and pigs suffered badly from cerebro-spinal fever. Rabbits,
mice and guinea-pigs are almost insusceptible to the action of
the meningococcus.
The limits of an outbreak may, therefore, not necessarily be
defined by the known cases, and, equally, the fatahty of out-
breaks is probably, as a rule, overstated.
This points to the need for early notification, before the
specific organism has become " domesticated " in a district, so
that confirmation of diagnosis by lumbar punctiure and bac-
teriological examination may further the application of prompt
preventive measures to the initial cases.
Farrar^ insists with much cogency upon the infectivity of
the disease, and adduces instances pointing to the conveyance of
the infection by " fomites," by aerial infection during expectora-
tion and sneezing, by kissing, and by the mediate agency of
contacts. Its " limited " infectivity is, at the same time, indi-
cated by its sometime presence in barracks without concurrent
prevalence in the civil population, and by the converse condition.
The epidemiological facts point to the persistence of the
organism with high potentiahty of infection for long periods,
followed by an explosive intensity upon occasion, as manifested
in fatal " house-epidemics ; " this activity is rapidly exhausted,
and these localised outbreaks, intensely virulent within a narrow
range, do not, as a rule, spread very far. In explanation of its
explosive epidemic virulence, he hazards the suggestion of a
symbiosis of the meningococcus with some other organism, such
as the micrococcus catarrhalis, or Pfeiifer's bacillus.
Prophylaxis, — ^Twq classes of people must be considered,
namely the " infected " and the " infective." It is apparently
necessary that the buccal and nasal cavities of possible " carriers "
should be washed out night and morning with a good stream of
warm dilute antiseptic solution, and swabs should be taken and
submitted for bacteriological examination at regular intervals.
^ Farrar, "The Infectivity of Cerebro-spinal Fever," Tr. Epidem^ Soc.
Lond., 1905-6, N.S., vol. XXV. 245.
3
Vol. XXV. No. 95.
Digitized by VjOOQIC
l8 DR. D. S. DAVIES AND DR. I. WALKER HALL
" Contacts " should be isolated and similarly treated.
As to the patient himself, effective isolation is very advisable.
His nasal and buccal cavities and hands should be kept continu-
ously clean. All the utensils he touches should be immediately
disinfected. Handkerchiefs, towels, linen, bedclothes should be
dipped at once after use into disinfectant solution. The room
which the patient has occupied should be thoroughly disinfected
Mervyn Gordon recommends medical *' Izal " for the purpose
of buccal and nasal disinfection, and places potassium perman-
ganate equal to mercury bichloride or silver nitrate. Almost any
disinfectant will serve the purpose, provided it is used sufficiently
strong.
Jehle employs pyozyanase, a proteolytic ferment. The
introduction of j&ve drops of this ferment serves to effectually
kiU the organism when present in the nasal fossae.
Diagnosis. — Lumbar puncture should always be made in
indefinite cases of meningitis. The skin should be specially well
cleansed, and a needle with a small bore employed. The fluid
should be received into a sterile tube, the tube at once plugged
with sterile wool, and transmitted for chemical, cytological, and
bacteriological examination. The characters of the cells afford
useful information, and the coccus itself can be isolated within
a few days.
The agglutination reaction is also of value. It may be
produced by a sample of blood withdrawn from the patient on
the sixth day and onwards.
The general features of the disease are thus described in the
memorandum of the Local Government Board, issued in 1905 : —
** An acute epidemic disease, characterised by profound dis-
turbance of the cerebral nervous system, indicated at the outset
chiefly by shivering, intense headache or vertigo, or both, and
persistent vomiting ; subsequently by delirium, often violent,,
alternating with somnolence or a shade of apathy or stupor ;
an acutely painful condition, with spasm — ^sometimes tetanoid —
of- certain groups of muscles, especially the posterior muscles of
the neck, occasioning retraction of the head, and an increased
sensitiveness of the surface of the body. Throughout the disease
Digitized by VjOOQIC
ON CEREBRO-SPINAL FEVER. I9
there is marked depression of the vital powers, not infrequently
collapse, and in its course an eruption of vesicles, petechiae, or
purpuric spots, or mottling of the skin is apt to occur. If the
disease tends to recovery, the symptoms gradually subside
without any critical phenomena, and convalescence is protracted ;
if to a fatal termination, death is almost invariably preceded
by coma."
Various forms are described, viz. : —
1. The fulminant form, attacking suddenly and killing
quickly.
2. The simple form, having typical nervous symptoms.
3. The purpuric form, attended by hemorrhages.
4. The abortive form, with anomalous symptoms, running
a short or irregular course.
A specific coccal pharyngitis or tonsilitis is a frequent early
symptom.
The predisposing causes upon which chief importance has
been placed are cold, dampness of soil, fatigue, and, in general,,
depressing influences ; also the influence of insanitary conditions^
especially such as generally accompany overcrowding.
Treatment. — In addition to the older remedies, withdrawal of
fluid by lumbar puncture and the frequent use of hot baths are
now generally advised. The proposed injection of i per cent,
lysol into the spinal canal has not met with general application.
Injections of mercurial cyanate and collargolsalbe may be placed
in a similar category. Westenhoeffer suggests incision of the
atlanto-occipital ligament during the second week of the attack.
This provides permanent drainage, prevents hydrocephalus, and
permits of local applications being made.
Serum Treatment. — Many attempts have been made to obtain
a curative serum. The earlier sera of Bonhoff, Lepierre, and
Lingelsheim, obtained after injection of the dead and living
cocci, had only slight protective effects. A similar result followed
the earlier use of aggressin. The names of Wasserman, Kolle,
Bnick, Bordet and Gengon, Mareschi, Neisser and Sachs, indicate
the amount of work and the eminence of the workers upon this
subject. The endeavour was next made to estimate the quantity
Digitized by VjOOQIC
20 CEREBRO-SPINAL FEVER.
and specificity of the immune bodies in the anti-serum. Inacti-
vated specific serum — ^meningococcal serum — ^was placed in a
test-tube, together with an extract from the cocci themselves,
and with some normal guinea-pig serum, and kept at 56^ C. for
about half an hour. The amboceptors of the anti-serum, the
receptors of the bacillary extract, and the complements of the
fresh serum were brought thus together. The addition of an
inactive haemolytic system (serum and blood corpuscles) was now
made in order to avoid ultimate haemolytic action. After two
hours in the incubator, and twenty-four hours on ice, specific
amboceptors appear and anchor the complement. In this way
the specificity and quantity of the amboceptors has been
•determined.
Five to ten c.c. of this serum are injected subcutaneously,
and the injection is repeated once or twice on the following or
alternate days.
Jochmann prepares a serum which is injected intra-spinally
in quantities of 20-30 c.c, after removal of 20-50 c.c. of the
spinal fluid by lumbar puncture. In this connection it may be
cited that lumbar puncture itself, by the withdrawal of toxins
and meningococci, is often followed by surprisingly good results.
The condition appears to be very favourably influenced by
the use of the serum, but it is as yet too early to quote any
•definite statistics.
It is possible that " vaccine " treatment may play a useful
part in later outbreaks.
Pathological Anatomy, — ^The main features consist of a thick,
purulent, creamy exudate covering the base, and sometimes the
cortex, of the brain. The Sylvian fissure is generally free from
exudate, but the upper surface of the cerebellum is the seat of
much exudate. These points are useful from a diagnostic stand-
point. In long-standing cases the meninges are fibrous, and
cerebral atrophy and serous, or purulent, internal hydrocephalus
are frequent. The cord shows similar conditions.
In addition, meningo-encephalitis often occurs, the glandular
organs generally show cloudy swelling, the spleen is enlarged,
there is often purulent bronchitis and lobular pneumonia, pleurisy
Digitized by VjOOQIC
DEFLECTIONS AND SPURS OF THE NASAL SEPTUM. 21
and pericarditis and joint troubles are not infrequent, and catarrh
and punctiform hemorrhages are present throughout the alimen-
tary tract, while the mesenteric glands are almost always enlarged.
The meningococcus can be obtained from either the nasal
cavity or the pharjmx. The organism appears to extend to the
meninges by the lymphatics, although it is not possible to entirely
exclude haematogenous paths of infection.
There are many gaps in our knowledge of this disease, and
every case is worthy of minute and careful observation and
record.
OPERATIONS FOR DEFLECTIONS AND SPURS OF
THE NASAL SEPTUM, WITH SPECIAL REFERENCE
TO SUB-MUCOUS RESECTION.
P. Watson Williams, M.D. Lond.,
Laryngologist and Rhinologist, Bristol Royal Infirmary: Aural Surgeon ,
Deaf and Dumb Inst, ; Lecturer on Diseases of the Nose and Throat,
University College, Bristol,
The nasal septum is formed by the triangular cartilage, the
perpendicular plate of the ethmoid, and the vomer, and is, there-
fore, divisible into the cartilaginous and the bony septum.
These structures forming the septum may become fractured,
dislocated, or deflected according to the nature of the injury
or other primary cause of deformity. The cartilaginous septum
is the most liable to dislocation or fracture, and most readily
yields when subject to other causes of deflection mentioned
below, and thus is most frequently the seat of defects requiring
interference.
Deformities of the septum are very variable in shape, and
it is convenient for clinical purposes to recognise three chief
varieties. Deviations or deflections which are (i) C-shaped,
as the septum may be bowed towards one side or the other, in
an antero-posterior direction or in a vertical plane. (2) S-shaped
Digitized by VjOOQIC
22 DR. P. WATSON WILLIAMS
where the bowing is in one direction anteriorly or below, and in
the opposite direction posteriorly or above. These C- and S-shaped
deflections are frequently due to or associated with dislocations
of the cartilage from the vomer, and are frequently combined
with the next class of ridges or thickenings along the line of such
dislocation. (3) Outgrowths, spurs, crests, or spines. These
are usually seen along the line of articulation of the triangular
cartilage with the vomer, and may or may not be accompanied
with actual dislocation of the cartilage. Fractures of the car-
tilage in a vertical direction due to traumatism, when the anterior
margin of the cartilage is usually seen projecting into one or other
nasal vestibule, are very frequently compHcated by thickenings
forming a ridge along the seat of the fracture, usually due to
local perichondritis and thickening of the mucous membrane over
the corresponding area. But such thickenings or ridges may
arise without any deflection or dislocation of the cartilaginous
or bony septum being obvious.
Causes, — 'In a very large number of cases no history of trau-
matism can be obtained. On the other hand, in a very large
percentage where marked deviation or spurs are present, the
history of a severe blow is obtainable, and leads to the conclusion
that even in the absence of such history some forgotten blow or
injury has been the determining cause, for it is obvious that very
few pass their time of childhood without being exposed to
causes which might give rise to such defects.
It is probable that in earlier Ufe any deflections of the septum
may be relatively slight in degree, symptoms only arising long
after, when, either from irritation in the region of the resulting
crest or from the gradual increase of the deflection due to the
suction action of respiration, the original deformity has become
aggravated. But considerable deformities and deflections of
the septum often exist without any symptoms whatever, and it
is certain that in at least a considerable number, when symptoms
ultimately do arise, it is owing to conditions which have lead to
turbinal hypertrophy.
The deformity of the palate resulting from nasal stenosis,
viz., the V-shaped or vaulted palate is considered by some
Digitized by VjOOQIC
ON DEFLECTIONS AND SPURS OF THE NASAL SEPTUM. 23
authorities to be a cause of septal deflections; while others
consider that these septal deformities are due to the developing
septum being out of proportion to the bony framework of
the nasal fossae. Probably in a certain proportion of cases
these developmental factors influence the origin of the septal
defects ; but I am more and more convinced that traumatism
is, even in the absence of the history of blows, by far the most
frequent cause of the condition.
F g. 1.
Diagram showing the formation of the high narrow palate and the
deformity of the nasal septum resulting from nasal obstruction.
The arrows indicate the line of action of the compressing force,
(After Lambert Lack.)
Inasmuch as many persons who complain of no symptoms
and exhibit no signs of nasal defects of any kind whatever are
found in the course of examination to have considerable septal
deflections or crests, it is important in determining the necessity
for interference to be guided by the presence or absence of
symptoms which call for removal of the septal defect. Yet very
distressing symptoms may arise in cases where the nasal passages
are suJG&ciently patent to allow nasal respiration from the lower
portion of the nasal passages, but where, either owing to organic
obstruction or to persistent nasal catarrh, the normal air tract
is so stenosed as to prevent respiration along that tract.
Investigations such as those of Scheff and Kayser, and of
Digitized by VjOOQIC
24
DR. P. WATSON WILLIAMS
Parker, have shown that the inspired air normally ascends in a
curved direction from the vestibule into the middle and superior
Fig. 2.
Diagram to show the normal path of inspired air through the
nasal passages.
meatus, and thence gradually descends posteriorly to the choanae*
(Fig. 2.) Stuffiness in the nose resulting from ordinary cold, and the
deficient respiration shown by children who are subject to adenoid
growths, is essentially due not so-
much to actual stenosis as ta
the rhinitis and catarrh which
prevents respiration through these
I normal air tracts. So we often
I find in cases of septal deflection
that patients exhibit symptoms
of nasal stenosis when the de-
flection is somewhat high up
and far back, while the combined
respiratory capacity of the lower
nasal passages would suffice for
respiration. The observance of
this fact becomes all the more important when one has to choose
the particular form of operation for the relief of a given case^
Fig. 3.
Double or S-shaped septal deflection
— rectified by sub-mucous resec-
tion, and by ablation of the over-
full anterior end of the left inferior
turbinal, — W. W.
Digitized by VjOOQIC
ON DEFLECTIONS AND SPURS OF THE NASAL SEPTUM. 25>
since we shall see that for this latter class the only satisfactory
method is that of submucous resection. (Fig. 3.)
Undue fuhiess of one or more of the turbinated bodies^
amounting to hypertrophy, may cause nasal stenosis, and it is
sometimes necessary to reduce the enlarged turbinal by the
galvano-cautery or by partial ablation. When the septum is
deflected, the turbinated body corresponding to the resulting,
concavity very frequently undergoes a compensatory hyper-
trophy, so as to project into and partly fill this concavity. In
some cases the nasal stenosis may be overcome from simple
reduction of the size of the turbinals, by removing quite a small
portion, rendering any interference with the septum unnecessary.
But when a septum has to be straightened, such hypertrophic
enlargement of the turbinal on the concave side will obviously
tend to block the air-way more than ever, so that the previously
patent side would become stenosed. This point must always
be taken into consideration before rectifying the septal defor-
mity, the anterior end of the hypertrophied turbinal, whether
it be the middle or inferior, being ablated or otherwise reduced
either a short time before or at the same time as the septal
operation.
Operative Methods, — Of the numerous methods that have
been advocated for the restoration of the septum, it is safe to
say that many will now be relegated to the past in view of the
eminently satisfactory results which can be obtained by sub-
mucous resection. Space prevents my alluding to more than
three of the chief methods now employed, viz. Gleason's
operation, Moure's operation, and sub-mucous resection, the
latter alone calling for detailed description on account of its
applicability to all cases and of the technical difficulties in its
performance.
Gleason's operation can be commended where one has to deal
with fairly hollow C-shaped deflections of the septum over a
limited area, restricted to the triangular cartilage, and where there
is no marked thickening of the septum as a whole.
It consists in making a U-shaped flap of the deviation either
by transfixing the deviated portion of the convex side by
Digitized by VjOOQIC
26
DR. P. WATSON WILLIAMS
a narrow-bladed knife, which is passed through the cartilage
just in front of the higher portion of the deflection, and
then made to reappear on the same side by transfixing the
cartilage again just posteriorly to the deflected portion, the knife
being then carried vertically downwards until it is below the
deflection, when it reappears ; or a saw is made to cut the de-
flection from below upwards with much the same result. In either
•case the tongue-like flap of septum, with its mucous membrane and
perichondrium intact, is hanging attached by its superior border.
To show the method of making the flap in Gleason*s
operation. — ^W. W.
This is then forcibly pressed through to the concave side with the
finger, care being taken to overcome the resiHency of the cartilage
at its attachment. (Fig. 5.) The obhque direction of the incision
ensures that the margins of the flap extend somewhat beyond the
margins of the septal incision : thu^ when the flap has been passed
through it cannot spring back again. If necessary, a splint is
inserted on the. concave side, sufficient to maintain slight pressure
on the margins of the flap against the corresponding portions of
the septum on the concave side, and this in the course of a few
Digitized by VjOOQIC
ON DEFLECTIONS AND SPURS OF THE NASAL SEPTUM. 27
•days results in union. In the majority of cases which are suitable
for the operation the result is very satisfactory, but it is obvious
that if the septum is thickened where it was deflected this
Fig. 5.
One method of pushing the
U-shaped flap in the septum
to the concave side.
Fig. 6.
Diagram showing how the
flap is automatically retained
in position.
i:hickening will be liable to cause obstruction of the formerly
patent side. (Fig. 6.)
Moure's operation consists in making the incision from before
^backwards, along the horizontal crest or lower portion of the
Fig. 7.
Showing the lines of incision in Moure's operation.
Digitized by VjOOQIC
28 DR. P. WATSON WILLIAMS
septal deviation parallel to the floor of the nose, and a second
incision parallel to the anterior margin of the triangular cartilage^
along the whole length of the deflection above, and with the
finger or suitable septum forceps causing fracture of the cartilage
towards the formerly unobstructed side, so as to overcome the
resiliency of the cartilage. The cartilage is kept in the new
position by means of Moure's or other suitable nasal plugs, and
these at the end of a week are dispensed with, when the union
has generally taken place. In some cases it may be necessary
to subsequently trim the margins. Here again it is obvious that
the operation can only be applicable to cases where there is
sufficient room on the non-obstructed side to receive the deflected
portion, and this can only be where deflection is simple, and has-
not undergone much thickening. (Fig. 7.)
The advantage of these operations is that they are quickly
performed, and do not call for such technical skill as is essential
for successful sub-mucous resection.
Sub-mucous resection essentially consists in the removal of
the deviated portion of the cartilaginous and bony septum, while
at the same time completely preserving the mucous membrane
and perichondrium, a thickened and deflected septum being'
replaced by one that is thin, straight and stiff. It is thus suitable
for every kind of septal deflection or spur, whether it is or is not
associated with thickening of the septum, while for cases where
the septum is considerably thickened it is the one method which
most satisfactorily overcomes the difl&culty, and ensures normal
and patent nasal passages without destruction of the mucous
membrane.
It is always possible in persons of good nerve and considerable
self-control to do this operation with local anaesthesia alone, but
the long time often required to do all that is necessary makes it
very trying to the majority of individuals ; and the prolonged
strain, even in the absence of pain, makes it preferable to resort
to general anaesthesia as a rule. If one depends on local anaes-
thetics, cocaine, eucaine, or novocaine can be used, and must
be appUed in solutions of considerable strength; but the
fact that cocaine is not infrequently trying to the patient makes
Digitized by VjOOQIC
ON DEFLECTIONS AND SPURS OF THE NASAL SEPTUM. 29
it the more desirable to have theni under general anaesthetics
whenever possible. In any case, adrenalin solution should be
applied, so as to cause vascular constriction, and it is important
to allow sufficient time for the action of the adrenalin to take
place before commencing the operation.
Difficulties attending local anaesthesia for septal resection would
seem to have been satisfactorily met by Miller's method of locally
applying a solution made by placing 20 grains of cocaine crystals
in a shallow dish, and dropping sufficient adrenalin chloride solu-
tion I to 1,000, to dissolve the ciystals. The solution is carefully
applied to the area of mucosae to be operated on. To better
the patient's self-control, he administers a draught just before
applying the cocaine, containing 10 grains each of the bromides
of sodimn, potassium and ammonium, with i drachm of
aromatic spirit of ammonia. Miller reports that his last forty
cases were operated on with this method of local anaesthesia
painlessly, and with minimum of hemorrhage.
The patient should be lying on the back, with head and
shoulders raised, and a very good illumination is essential.
The incision for simple ridges and spurs should extend from
behind forwards along the summit of the ridge in its whole
length, turning upwards for a quarter of an inch at the anterior
extremity, the subsequent stages of the operation being similar
to that for general deflection.
There are three different methods of incising the mucous
membrane : — (i) The triangular J -shaped incision ; (2) the
single buttonhole incision ; (3) the author's method of incising
the mucous membrane on both sides.
J -shaped incision. — If the variety of deflection is double-
angled, with a vertical and horizontal crest, as shown in the
accompanying figure, the first incision is usually made as sug-
gested by Freer, along the angle of vertical deflection, beginning
high up above the deflection, and extending right down to the
horizontal ridge. Then a horizontal incision is made along the
crest of the ridge, extending from the bottom of the vertical
cut forwards almost to the front of the septum. This incision
should cut just into but not through the cartilage, for if the
Digitized by VjOOQIC
30 DR. P. WATSON WILLIAMS
muco-perichondrium be not divided, when one comes to lift the
muco-perichondrium the mucous membrane alone may be
separated and raised from the perichondrium beneath, instead
of both being together raised from the cartilage. A triangular,,
anterior flap of muco-perichondrium is thus outlined, and this
Fig. 8.
The j-shaped incision, the mucosa being raised towards the front,
exposing a triangular piece of the cartilage, which is cut through
along the dotted line corresponding with the base of the exposed triangle.
should be carefully reflected, and then held forward by a small
pledget of wool, much care being taken to avoid perforation of
this anterior flap. The muco-perichondrium is then raised below
the horizontal incision by means of a suitable elevator right down
to the floor of the nose. Next the perichondrium of the septum
posterior to the vertical incision is lifted until the whole has been
removed corresponding to the septal deflection, extending down
to the floor of the nose, and if necessary to the posterior
border of the vomer: In this way the cartilage, and where
necessary the bony septum, is bared and exposed on the
convex side over and somewhat beyond the whole area
of deflection. Either with a round-edged chisel or a suitable
Digitized by VjOOQIC
ON DEFLECTIONS AND SPURS OF THE NASAL SEPTUM. 3r
septum knife, the cartilage is then incised, the incision ex-
tending along the base of the triangular flap, care being taken
to leave at least a quarter of an inch corresponding to the anterior
free border of the septum above, in order thsCt there may be no
risk of the falling-in of the nose. The incision must not extend
through the perichondrium on the opposite side, and in making
this incision the left forefinger should be inserted into the opposite
nostril, so that no puncture shall be made. The muco-peri-
chondrium is then raised from the concave side over the area
corresponding to that alluded to in the first instance, care being
taken to make the reflection right down to the floor of the nose on
this side too.
The single buttonhole incision may be made about a centi-
metre and a half behind the septum cutaneum or columella,
near the floor and extending upwards and forwards, being about
threequarters of an inch long, nearly parallel to the anterior free
margin of the cartilage but curving away from it below. The
muco-perichondrium is then lifted on the convex side as in the
first instance, but without making any triangular anterior flap.
The cartilage is next incised without cutting through or perforat-
ing the mucosa on the opposite side, and the muco-perichondrium
Hfted from the concave side from before backwards.
The author's method of incision on both sides. — In many
cases it is a matter of difficulty to incise the triangular
cartilage in the manner described above without perforating the
perichondrium, which is lying intact with it ; and in order to avoid
this contingency I have been in the habit of first making a small
incision of the mucous membrane on the concave side, well in
front of the site selected for the usual buttonhole incision, which is
to be made on the convex side. A very narrow elevator is inserted
so as to raise the muco-perichondrium, and by a movement of the
distal end of this elevator upwards and downwards the muco-
perichondrium is lifted from a considerable area on the concave
side. (Figs. 9 and 12.) The elevator is then drawn out through
the initial puncture, much as one would use a tenotomy knife.
In this way the muco-perichondrium on the concave side,
having already been lifted, when the incision comes to be made
Digitized by VjOOQIC
.32
DR. P. WATSON WILLIAMS
^•1
:5 Q
*~ e o u
bb s o 8
•52 <« •«
o o
a ^
g-5
o -§§
ho
Digitized by VjOOQIC
ON DEFLECTIONS AND SPURS OF THE NASAL SEPTUM.
33
in the usual way through the cartilage from the convex side
there should be no risk of perforation, because the curtain of
muco-perichondrium on the concave side is simply pushed in
Fig. 11.
Narroiv perichondrium reflector for use on the concave i>idc.
front of the knife. The subsequent stages of operation are the
same, whatever incision has been made. (Fig. lo.)
Speaking generally, the advantage of the L-shaped incision
is that the incisions are made along the crests or angles of the
<ieflections, and, as Freer has pointed out, it is easier to dissect the
Fig. 12.
Fig. 13.
The two curtains of muco-peri-
chondrium held opart, exposing
the cartilage.
-ixiuco-perichondrium from the summit of the ridge downwards
•on either side than it is by incising altogether in front of it to
dissect the perichondrium first up to and along the summit and
downwards along the farther side. Especially is this an advantage
if the vertical ridge be sufficiently near the front to be accessible.
When, however, the deflections are situated well back it is a
4
Vol. XXV. No. 95.
Digitized by VjOOQIC
34 DR. P. WATSON WILLIAMS
greater advantage to utilise the buttonhole incision, or, to my
mind, the double buttonhole which I have described.
Having thus laid bare the entire area of the septum, both
cartilaginous and bony, corresponding to the deflections which
may extend only to the quadrilateral cartilage, or, as we have
seen, occupy the vomer and perpendicular plate of the ethinoid
it finally remains essential to remove the whole of this deflected
area. If any portion of the deflected area be left above or below,,
although it may seem insignificant as the cause of subsequent
stenosis, it becomes of importance owing to its preventing the
two curtains of muco-perichondrium (Fig. 13) hanging vertically
in apposition in the mid-line, therefore interfering with their
subsequent adhesion, and also because any intervening space may
become filled with blood-clot, which may suppurate or become
filled up with granulation tissue, leaving a thickened or
irregular septum, instead of a thin, straight septum, which is
the great end of the operation. In removing the deflection, it is
convenient to hold apart the two
curtains of muco-perichondrium by
means of a long speculum, such as
St. Clair Thomson's (Fig. 14) or
Tilley's, or one may use Killian's
speculum for median rhinoscopy.
The cartilage should be removed
by Ballenger's swivel knife (Fig. 15),
applying it either at the lowermost
part of the cartilaginous margin, or
the uppermost angle, carrying it for-
wards until it reaches the bony
Fig. 14. septum, being then turned upwards
St. Clair Thomsons speculum, or downwards as the case may be,
and encircling if necessary the whole
of the cartilage between the maxillary crest to within a
quarter of an inch of the superior free margin of the cartilage.
The knife is drawn out, having cut through the cartilage,
which can then be lifted out readily with forceps. Subsequently
the perpendicular plate of the ethmoid or vomer, if the
Digitized by VjOOQIC
ON DEFLECTIONS AND SPURS OF THE NASAL SEPTUM.
35
(ff
seat of deflections or crests, are clipped away with cutting
forceps.
The maxillary nasal spine and vomerine ridge must now be
dealt with. The nasal spine ma}'
be prised away v/ith forceps or
removed by hammer and chisel,
great care being taken not to
wound the lower portions of the
perichondrial flaps. If the ridge
posteriorly is displaced or thick-
ened it is clipped away, and then
it only remains to wash away the
debris, bring the curtains of muco-
perichondrium into position, and
very lightly pack the nasal pas-
sages on either side with strips ol
gauze, just sujG&cient to exert
very slight pressure. By these
means we keep the two flaps in
their position, and not only ensure primary union, but prevent
the accumulation of blood between the layers, which may
cause subsequent trouble by suppurating. The following day
all packing may be removed and the nose cleansed with warm
antiseptic and alkaline solutions, which may be repeated daily
Fig. 15.
Ballengers swivel knife, modified
to hold flaps of mucosa apart on
cutting the cartilage.
Fig. 16.
Wood's forceps for removal of maxillary crest.
until at the end of a week the parts will be healed and complete
union have taken place.
The drawback to the operation, which has such eminently
Digitized by VjOOQIC
36 DR. p. WATSON WILLIAMS
satisfactory results, is that it takes considerable time, and though
much care and patience be observed, perforation may result.
Although these, if far back, may be of no moment, yet when they
are near the anterior end of the septum thej^ are found to catch
dust or form crusts, or if they are only small perforations they
may cause whistling sounds during respiration through the nose.
Such contingencies, however, would rarely happen in the hands
of a skilful operator.
Occasionally a septum becomes not only enormously deflected,
but in process of development obviously increases out of all pro-
portion to the other nasal structures. In one case under my care
the deflection was so pronounced that the angle caused a slight
•elevation on the outside of the nose, and extended right across
the nasal passage so as to completely obtrude it, while the posterior
deflection on the opppsite side also caused stenosis there. The
intervening area on the concave side showed an enormous
depression, which at first sight looked like a very large perfora-
tion. The case also was complicated by double empyema of the
antra, doubtless mainly resulting from the retention of the nasal
secretion owing to the deflections. In this case it was quite im-
possible to do resection, and the only way to relieve it was to
resect a portion of the septum and leave the perforation.
It is remarkable that despite the entire removal of the car-
tilage between the layers of the perichondrium, which for a time
will move like a curtain when touched with a probe, or even
•during respiration, yet nevertheless will become so stiff in the
course 6i a few months as to give rise to the impression that
cartilage has re-formed, which, of course, never can occur.
A very large number of these operations have now been
done over a period of several years, and there seems to be no risk
•of depression of the nose externally. But in order to render this
impossible, it is desirable to leave a quarter of an inch of free
margin corresponding to the upper border of triangular car-
tilage above the lateral cartilage. Cases have been recorded
where even a severe blow on the nose in patients who have
undergone sub-mucous resection no deflection or depression has
resulted.
Digitized by VjOOQIC
ON DEFLECTIONS AND SPURS OF THE NASAL SEPTUM. 37
How far one can wisely remove the bony or cartilaginous
septum in children it is hardly safe to say without a larger
number of cases before us than have yet been reported, but
several instances in which quite young children have undergone
the operation successfully, and without interference with their
nasal development, have been recorded, and I have myself in
one case removed a large portion of the anterior end of the
triangular cartilage in a boy aged nine, and although that was
a
Fig. 17.
Showing the actual area of the septum removed unth excellent results
in one of the author s cases.
several years ago and he is grown up, his nose has developed
well without trace of depression.
Indeed, it may be said that in children where stenosis exists
nasal development would be far more interfered with if the cause
be left, apart from all the other unfortunate results to nasal
stenosis in a growing child, than could be the case from an
adequate removal of the septal defects.
The Krieg-Bonninghaus operation, known also as the Fenster
resection, consists in removing the whole of the cartilage or bone
forming the deflection, together with the corresponding part of
the muco-perichondrium on the convex side, and leaving the
single bared muco-perichondrium of the concave side to form the
new septum. It was originally introduced by Krieg and revived
by Bonninghaus in 1900, but though still preferred by some
Digitized by
Google
38 TWO CASES OF RUPTURED INTESTINE.
operators, has been generally superseded by the more satisfactory,
though slightly more difficult, operation of sub-mucoiis resection.
An J -shaped incision is made on the convex side, the vertical
incision in front of, and the horizontal extending below the whole
of the deflection. The incision is made to cut through the
cartilage without perforating the mucosa of the concave side,
which is then raised as in the sub-mucous operation. The deflec-
tion, together with the mucous membrane of the concave side,
is then removed bodily by scissors or cutting forceps. The fact
that this procedure leaves a large bare surface of the muco-
]-)erichondrium of the other side, which takes some weeks to
granulate and become covered with epithelium, is a serious draw-
back, though the ultimate result is usually satisfactory. The
operation is nearly as difficult and tedious as the sub-mucous
method, but the after-treatment is much more tedious, and the
result is not so certain to be satisfactory, and I now never have
recourse to it.
REFERENCES.
Bonninghaus — Arch. f. Laryngol, ix. 269.
Freer — /. Am. M. Ass., 1902, xxxviii. 636; 1903, xli. 1391 ; Tr. Am.
Laryngol. Assoc, 1905, p. 29.
Hurd — Med. Rec, 1905. Ixviii. 853.
Killian — Verhandl. d. Gesellsch. d. Nat. u. Aerzt, 1899.
Kreig — Berl. klin. Wchnschr., 1899, xxvi. 699, 719.
Lack — Diseases of the Nose, 1906, pp. 65, 104 et seq.
Miller — Med. Rec. No. 8, Ixxi. 311.
Moure — /. Laryngol., 1901, xvi. 163.
Parker— /fezrf., 1901, xvi. 345.
Schefl and Kayser — Ihtd., 1895, ix. 64.
St. Clair Thomson — Med.-Chir. Trans., 1906, Ixxxix. 655.
TWO CASES OF RUPTURED INTESTINE.
BY
Harold F. Mole, F.R.C.S.,
Assistant-Surgeon and Surgeon in Charge of the Aural Department,
Bristol Royal Infirmary.
As cases of rupture of the intestine do not appear to be very
common, and as, at any rate, cases operated on are seldom
reported, it seems to me that these two successful ones are
worthy of record.
Digitized by VjOOQIC
TWO CASES OF RUPTURED INTESTINE. 39
Case 1. — ^Joseph K., aet. 35, was admitted to the Bristol Royal
Infirmary on the evening of July 27th, 1904, complaining of
severe abdominal pain. He had been struck in the epigastric
region, slightly to the left of the middle line, by the pole of a
swing-boat. He was taken unawares, being quite unprepared
for the blow. He walked into the Infirmary. He was an ex-
ceedingly poor man, and had had no food for eight hours. He
was much collapsed immediately after the blow, and in a few
minutes vomited. After a time he recovered sufficiently to walk
to a tram and come to the Infirmary. On admission he was
rather collapsed, his abdomen hard and tender in the upper part,
pulse good, 62, and temperature 95'^ F. He was watched for two
hours, and during this time vomited three times, the total amount,
however, being only two ounces. I saw him at this time, and
his pulse was 72, very good, his temperature 97^ F., and his
abdomen rather hard and tender in the epigastric region. There
was some blood in the vomit, corpuscles being seen with the
microscope. The nature of the accident and the history strongly
suggested to me a rupture of the intestine, and' the abdomen was
opened at once, four hours after the accident, by a median incision
above the umbihcus. Blood appeared on opening the peritoneum,
and on displacing coils of intestine was seen to come from the
neighbourhood of the spleen. There was no sign of stomach or
intestinal contents except a little sticky mucus. The stomach
and spleen were carefully examined, but no rupture detected. The
small intestine was then pulled out from the upper abdomen,
and upper part of the jejunum being exposed, a large tear was seen
involving nearly half the circumference of the bowel, but being
placed obliquely to its long axis, in its fixed part just beyond the
duodeno-jejunal junction. The thick mucous membrane was
markedly everted, giving rise to a red-looking tumour. The
blood was mopped out, and the mucous membrane sewn up with
a continuous catgut stitch. The peritoneal and muscular coats
were brought together with interrupted Halsted's stitches, and
outside these one or two supporting Lembert stitches. The
suturing was a little difficult owing to the fixed position of the
bowel posteriorly. The abdomen was washed out with saline,
and some of this left in, and a large cigarette drain inserted down
to the line of suture. The rest of the wound was sewn up. Four
days later the drain was removed and replaced by a very much
smaller one, which was removed next day. He was allowed only
water and brandy by the mouth for the first few days, and was
given nutrient enemata. Other fluids were soon added, but no
actual solid food until the fourteenth day, when the stitches were
removed. He made an uninterrupted recovery, and never
thought there was much the matter with him ; consequently,
we had great difficulty in keeping him in bed and making him
submit to the restricted diet. He was discharged on the twenty-
Digitized by VjOOQIC
40 MR. HAROLD F. MOLE
eighth day, and seen about a year later was remaining quite
well.
Case 2. — Charles J., aet. i6, was admitted to the Bristol Royal
Infirmary on the morning of September 17th, 1906. He was
working in a fitting shop when the arm of a crane swung round
and struck him in the abdomen, pinning him against some railway
sleepers. He was set free by the wood being sawn away from
behind him. He then, to use his own expression, got up, put his
hands in his pockets and walked to the office. On admission he
appeared to be somewhat concussed (there was a scalp woundV,
and the abdominal symptoms masked ; he was somewhat pale,
pulse 84, and temperature 97'' F. Abdominal rigidity soon
appeared, and rapidly became more marked. He also became
blanched, and in two hours his pulse rose from 84 to 120 per
minute. When I saw him, about four hours after the accident,,
he was clearly suffering from internal hemorrhage. Pallor was
extreme, pulse 136, restless, and much abdominal pain and
tenderness, with rigidity most marked under the upper part of
the left rectus. I made a probable diagnosis of rupture of the
left lobe of liver or spleen, and would have operated at once, but
had to wait nearly two hours to obtain the consent of the parents.
Six hours after the accident I made an incision in the middle line
above the umbilicus, and rapidly examined the liver and spleen,,
and found them normal. From amidst a large mass of blood-clot
to the left I delivered a piece of intestine, jejunum I judged by its
thickness, completely torn through transversely in its whole cir-
cumference, and including two to three inches of its mesentery.
It might almost have been done with a pair of scissors, except
that the mucous membrane was somewhat jagged. The mucous
membrane was everted, and what I took to be the upper end of
the bowel was filled with blood-clot. There was an artery spurting
in the mesentery. There was no sign of extravasation of intestinal
contents. I judged that the injury had probably been caused by
the crane tearing the bowel across the spine. The bleeding vessel
was ligatured, the mesentery sewn up on either side with sutures
apphed after Lembert's method with silk. A continuous stitch
brought the mucous membrane together, and the peritoneo-
mtiscular coats were united with continuous Lembert sutures
starting on either side at the end of the mesenteric sutures and
being united in the middle line. As the bowel could be delivered
outside the parietes, the suturing was easy, and was performed
rapidly, as the condition of the patient was precarious. No
attempt was made to swab or wash out the abdomen or to remove
the blood-clot. Sahne fluid was run into the abdomen whilst the
wound was being sewn up, and no drainage was made. For the
remainder of the day the boy was extremely bad, and had rectal
injections of saline, and saline infusions into the veins, nutrient
enemata, and only water and brandy by the mouth. His tem-
Digitized by VjOOQIC
ON TWO CASES OF RUPTURED INTESTINE. 4I
perature rose to ioo° F. the night of the operation, but there was
never fever after this. For two days his condition gave rise to-
some anxiety from abdominal distension and rapid pulse, but
after this his recovery was interrupted. He ate chicken on the
ninth day, the stitches were removed on the fourteenth, and he
was discharged at the end of a month. I saw him two months
after, and he seemed quite well.
In addition to these two cases, I have distinct recollection of
three others under the care of my colleagues during the past five
or six years, two of which recovered and one died. The latter
was extremely bad at the time of operation, and his abdomen was
found full of faeces. I am therefore led to suppose that trau-
matic ruptures of the intestine uncomplicated by other serious
abdominal injuries give very favourable results when operated on
early. It is therefore of the first importance to make an early
diagnosis. This is by no means always easy, for the symptoms
may be very equivocal, and cases are on record where patients
have walked long distances after this accident. I am disposed to lay
considerable stress on the nature of the accident. This will be found
most usually to be a sudden, well-localised blow. Of causes that
have actually come under my own observation may be mentioned
the following : — A kick from a horse, coming in contact with the
point of a shaft of a cart whilst riding a bicycle, falling on to the
handle of a pick, and being struck by the point of a pole (Case I.)..
There is usually initial collapse, and frequent vomiting is said to
be an important symptom. When it is present I think it is so, but
I don't know that I should feel inclined to lay a great deal of
stress on its absence. My second case had none. The one
symptom which I think is, perhaps, of more value than any other,
following on such an injury as I have suggested, is rigidity of the
abdomen. This may be marked or only slight, and limited to the
area struck, but it is none the less of great importance. There
were some who thought there was hardly sufficient indication to
operate in my first case, but the nature of the accident, plus the
rigidity, decided me. There was also frequent vomiting, con-
sidering the length of time that elapsed and the absence of food
from the stomach. The pulse, however, was no assistance what-
ever, and this is not infrequently the case, whilst in another class
Digitized by VjOOQIC
42 TWO CASES OF RUPTURED INTESTINE.
of abdominal conditions, notably appendicitis, it may be the best
guiding sign of the serious condition of the patient. I was fortu-
Tiate in these two cases in that there was no obvious extravasation
of faeces in either. This was accounted for to some extent by the
bowel being more or less empty, but also by the way the thick
mucous membrane of the jejunum becomes everted, almost com-
pletely blocking quite a large hole. Blood-clot also helps to block
the opening. My second case was of interest in that the symptoms
of internal hemorrhage quite masked those of intestinal rupture,
and thus made it a complicated case. The blood came from torn
'vessels in the mesentery. It would appear that in cases of this
kind, without visible faeces in the peritoneum, it is quite safe to
•sew up the abdomen without drain, as is shown by my second
case, and I have little doubt my first would have done equally
well, but I felt a little uncertain about the suturing as it was
difficult. It is also clear that it does no harm to leave a large
mass of blood-clot in the abdomen. With regard to the vexed
question of flushing the abdomen, I would suggest that this
procedure be limited to those cases in which there is wide
•diffusion of faeces, and that in the other cases the locally infected
area be carefully swabbed dry, with as little disturbance of the
neighbouring parts as possible. Treves says, in his System of
Surgery {1896), that the jejunum is the most common seat of
rupture (two of the three other cases referred to were ileum, and
the third I do not remember), that in only 16 per cent, of all cases
is the rupture complete, that in about 70 per cent, there is
escape of faeces into the peritoneal cavity, and that in about 15
per cent, there is a rent in the mesentery. The following results
of operation are given : 24 cases of incomplete rupture with 11
deaths, and 4 cases of complete rupture with 3 deaths.
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CONCLUDING NOTES ON A CASE OF
SPLENOMEGALIC CIRRHOSIS IN A CHILD AGED
SEVEN YEARS.
Edward Cecil Williams, M.B.Cantab.,
Physician to the Royal Hospital for Sick Children and Women, Bristol.
Twelve months ago I showed before this Society a boy, aged
six years, with enlargement of Hver and spleen, slight jaundice,
stunted growth, and clubbing of fingers and toes. Abdomen
was enlarged, surface veins distended. Liver dulness extended
from the sixth rib to the level of the umbilicus. Spleen also
much enlarged, extending within a couple of fingers* breadth of
the iliac crest in the mid-axillary line ; its notch could be felt
on the outer border within 2j to 3 inches of the middle line ; it
-was dense and smooth. No evidence of ascites, no oedema of legs,
but on each leg a few petechiae. There was nothing distinctive
in the blood picture. I regarded the cHnical signs as falling in
with the juvenile group of cases described by Gilbert and Fournier.
On March 7th, 1906, the boy was discharged improved — ^no jaun-
■dice, liver not diminished in size, spleen certainly smaller. His
motions had averaged one or two daily ; they occasionally con-
tained blood. The urine on only one occasion contained albumin.
The boy was readmitted on May 9th, 1906. Liver was two inches
below costal margin and was felt to be nodular. Spleen as before.
Towards the end of June he was not so well, had slight rises of
temperature, was drowsy, and abdomen began to fill. There
-was haematuria and oedema of legs, with blood in the motions.
His mouth was ulcerated, and there were petechiae on the legs.
During the month of July paracentesis abdominis was performed
three times, and 4J, 34 and ij pints of fluid were withdrawn,
-which afforded the patient much relief. The rises of temperature
and drowsiness, with petechiae and pain in the left side, seemed
to denote an extra dose of poison in the system. On August 8th
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44 DR. EDWARD CECIL WILLIAMS
there was a slight reaccumulation of fluid, and 12 ounces were
withdrawn. During September the child gradually lost ground*
On October 2nd 36 ounces were withdrawn ; child was very
anaemic, with a murmur over the mitral area ; skin again yellow,
with traces of bile in the urine. About a month before his death
he suffered from diarrhoea, with profuse watery motions, some-
times bloodstained. The motions averaged six, seven, and
occasionally more a day. There was no further accumulation in
his abdomen until a few days before his death, on November 27th.
Leucin and tyrosin were not found in the urine. There was never
any reason to suspect alcoholism, nor were there any signs of
congenital syphilis. There was a doubtful history of paternal
syphilis.
It is difficult to say what amount of splenic enlargement
justifies the use of the word " splenomegaly.'' In my case the
spleen seemed, when the child was first admitted, to be of excessive
size. There is no doubt the spleen did diminish in size as the
disease progressed. At the autopsy the spleen was found to-
weigh nine ounces, which is three times the average weight of a
child aged seven years. The liver weighed i lb. 9 oz. Macro-
scopically it looked markedly cirrhotic, while microscopically a
coarse, multilobular cirrhosis was the outstanding feature, with
some increase in the number of bile-ducts. This condition cannot
have anything to do with Banti's disease, which is the termination
of the splenic anaemia of adults in multilobular cirrhosis and
ascites. The second dentition is the earliest age at which the
splenic anaemia of adults occurs, and the splenic anaemia of infants
iSk a totally distinct affection, which seldom occurs after the age
of two years. The poison may be manufactured in the intestine
and conveyed to the liver by the portal vein, and thence to the
spleen, or it may be introduced into the systemic circulation and
have a selective affinity for the liver and spleen. There is no
history of any infectious disease in my case as in some of the
cases recorded by other observers.
The notes on the post-mortem appearances by Dr. J. M.
Fortescue-Brickdale were as follows : —
The child was emaciated and jaundiced. The thyroid was
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ON A CASE OF SPLENOMEGALIC CIRRHOSIS. 45
normal, the thymus was fibrotic and wasted. There were ex-
tensive pleural and pleuro-pericardial adhesions, especially on
the left side in front. The left pleural cavity was, however, not
completely obliterated, and contained some milky fluid, which
showed no fat globules under the microscope, and coagulated
readily on heating. The heart was normal ; the lungs somewhat
ced matous. There was a considerable amount of ascites. The
small intestines were normal ; there was a small recent ulcer in
the caecum, and the colon appeared thickened and- oedematous.
The liver weighed i lb. 90Z. ; it was '' hobnailed '* in appearance,
and the left lobe was especially shrunken and fibrotic. The spleen
was firm and dark ; it weighed 9 oz. There was perihepatitis
and perisplenitis. The kidneys were normal.
Microscopically the spleen showed some congestion of the
Malpighian follicles and thickening of the capsule and trabeculae ;
the liver showed a cirrhosis of multilobular type, and in places
there were collections of bile-ducts in the fibrous tissue bands,
but it was difficult to say that any definite increase in these
existed.
From the pathological appearances it was not possible to say
which organ, liver or spleen, was first affected. There was nothing
inconsistent with the diagnosis of splenomegalic cirrhosis of
infantile type, as may be seen by reference to the published
reports of cases. Dr. Taylor's case' gives a very close parallel,
and in Dr. Parkes Weber's case' a similar coarse fibrosis of the
liver existed. The spleen in the present instance, though en-
larged, was certainly smaller than in most recorded cases ; but
in Gilbert's paper, ^ cases in which the spleen is only moderately
enlarged are definitely included in the group.
There was no pathological evidence of syphilis, unless we are
prepared to say that any case of obscure fibrosis of the liver is
due to this cause. The number of bile-ducts and the character
of the fibrosis were not such as to suggest Hanot's disease, and,
moreover, there was no leucocytosis during hfe.
> Guy*s Hosp, Rep., 1897, liv. i.
* Tr. Path. Soc. Lond., 1895, ^Ivi. 71. '* Semaine mJd., 1900, p. 186.
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ACQUIRED ANGIOMA OF THE LIVER.
BY
A. Lewin Sheppard, M.B., B.S. Durh.,
House Physician to the Bristol Royal Infirmary.
The following article includes a description of a case recently
in the wards of the Royal Infirmary under the care of Dr. Shaw^
to whom I am indebted for permission to publish the case.
The patient, a man of 50, was admitted to the Bristol Royal
Infirmary on November 21st, 1906.
The history of his illness was as follows : — About a year ago
some " yellowness of the^eyes '* was noticed. Five months ago-
he began to complain of pain over the lower part of the chest
and epigastrium. Three weeks ago he became worse while at
work, and had to sit down, eventually going home to bed. After
a fortnight in bed, during which the jaundice became more
marked, he tried to put his clothes on, but found his trousers
would not meet by several inches, owing to enlargement of the
abdomen. He returned to bed, and the swelling increased some-
what rapidly until admission.
Past history. — ^An electrical engineer at a large factory for
the last 25 years, he had lived in Bristol all his life with the
exception of a few months at sea. He had enteric fever four years
ago. No other illness. No haemorrhoids. Rarely missed work.
He drank a good deal of whisky. Appetite good, but occasional
retching in the mornings. No specific history.
Family history. — Mother died of old age at Sj. Father healthy,
aged 89. His wife had had eleven children, of whom ten are
alive ; eldest aged 23. No miscarriages.
Condition on admission. — Big, well-nourished man. Decidedly
jaundiced. Temperature, normal ; pulse, 90 ; respirations, 28,
Nothing abnormal found in heart or lungs. Arteries, not
markedly thickened for his age; slight oedema of legs. Urine
(first 24 hours' specimen), 22 ounces, brown, s.g. 1012, cloud of
albumen, bile. Abdomen, greatly distended ; signs of free fluid ;
measurement, 43^ inches; some large veins running upwards
from lower part of abdomen; enlarged liver just felt through
fluid; no pain.
Progress. — ^Abdomen increased in size and tension to 44
inches, when paracentesis abdominis was performed in the middle
line through a -& inch trocar, the patient lying on his side.
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ACQUIRED ANGIOMA OF THE LIVER. 47
Six pints, five ounces of semi-opaque fluid, typical of ascites due
to portal obstruction ,was the result. The operation lasted 25
minutes, the fluid running slowly and the patient showing no
signs of collapse. Immediately afterwards a nodular hard mass,,
the size of a tennis ball, was easily felt in the epigastrium, in
consequence of which a malignant growth of the liver was sus-
pected. The rest of the edge of the liver could not be made out..
An abdominal binder was applied. This was the fifth day after
admission. The following day he complained of pain in the
abdomen, which now measured 42 inches, and during the following
days the pain became more and more severe, the patient requiring
both strychnine and morphia. Temperature, normal ; pulse,
feeble. This continued for nine days, when he died, the pain^
never having abated, and the fluid having rapidly reaccumulated.
Post-mortem examination. — Heart, normal. Vessels, healthy.
Lungs, normal. Spleen, enlarged, hard and congested. Kidneys,
enlarged and congested, bile stained. Pancreas, shghtly harder
than normal. Glands, no enlargement found, no malignant
focus. No peritonitis. No angiomata found in other organs.
Liver : weight 7 lb. 12 oz. ; colour : brown, bile stained ; capsule :
adherent and of normal thickness; surface: masses of large,
irregular nodules, most marked on the anterior surface, especially
in the left lobe, which was enormously enlarged, and of a bluish
colour, where it was soft and spongy. Antero-posterior section
through the left lobe showed non-capsulated small dilatations
throughout, varying in size from a pin's head to a pea ; few in
the posterior part, but closely packed together in the anterior
segment. These dilatations contained blood, and the anterior
part was discoloured and nearly black, fading posteriorly into
the ordinary colour of an early cirrhotic liver. [Vide Fig. i.)
Microscopical sections showed as the most marked feature a
separation of the individual hepatic cells, i.e, intercellular spaces..
In some collections of lobules this condition was exaggerated until
cysts were formed, and large spaces were seen in various stages
of development. In more recent ones were seen liver cells lying
diffusely through the space, but the more cells so found the less
distinct was the boundary of the cyst, formed as it was by the-
liver cells only. In the older spaces this condition was reversed,
few or no cells lying within the space, but the edge was more
defined, and in more marked cases the liver cells were lying
concentrically, as if due to prolonged pressure. The portsd
systems on the whole were normal. (Vide Fig. 2.) In some
places there was a slight appearance of cirrhosis and elastic
tissue, while in isolated patches there is some small-celled in-
filtration around the blood sinuses throughout the lobules. The
liver cells generally are neither atrophied nor damaged. Sections
stained by Weigert's resorcin-fuchsin stain, in addition to the
usual methods, demonstrated the absence of fibrous or elastic
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48 DR. A. LEWIN SHEPPARD
tissue in the small-celled infiltration which surrounded some
of the larger cysts. The cystic dilatations were principally to
be observed in the area of the hepatic veins, and appeared to
•develop from dilatation of the lobular veins, or by extravasa-
tion into the central areas of the lobules. These areas were
previously in a state of advanced venous congestion, oedema
being particularly well marked. The induration stage of passive
hyperaemia was missing, and its absence may account for the
unusual extent of the hemorrhages which are usually associated
with that condition.
According to Rolleston,^ angiomata of the liver can be
injected from the hepatic artery, or from the hepatic or portal
weins.
Remarks. — ^The case is of interest for several reasons.
Firstly, few are recorded. Lancereaux^ mentions 25, and
Schmieden 3 32 cases, 18 of the latter being single and 14 multiple.
They are said to be commoner in men, but Thoma* denies this.
Secondly, they may be acquired or congenital, and have
been seen in foetuses. (They are said to be comparatively
• common in cats.) According to Rolleston,^ the acquired is
the commoner variety, and they are then probably due to a
combination of local congestion of the hepatic vessels and
atrophy of the liver cells. Usually they are quite small, and
only very occasionally have large cavernous tumours been
seen in adults. In two such cases angiomata were found in
other abdominal viscera. Large tumours of this type are
usually encapsulated. The case in question was probably
acquired, for the following reasons : — ^The age of the patient ;
the definite history extending over a period of one year, with a
more acute stage of about five months ; the irregular character
of the condition as regards capsulation, and the extremely large
size of the liver, which must have been noticed had it not increased
very rapidly during the periods mentioned ; the complete
.absence of any past history of liver trouble ; and also, possibly,
the slightly cirrhotic condition, connected as it was with a dis-
^ Encyclopedia Medica, 1900, vi. 531,
' Trait'' des maladies du foie et du pancreas, p. 528.
^ Arch. f. path. Anat., 1900, clxi. 373.
* Pathology. English translation by Bruce, i. 553.
^ Diseases of the Liver, Gall-bladder and Bile-ducts, 1905, p. 461
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ACQUIRED ANGIOMA OF THE LIVER.
Fig. 1.
Photograph of antero-posterior section, showing darker area of
angioma and spaces from which the blood has been
washed out. Slightly less than half size.
Fig. 2.
Micro-photograph of section of angioma, showing different
types of blood spaces, and a portal system.
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ON ACQUIRED ANGIOMA OF THE LIVER. 49
tinctly alcoholic history. The congenital condition is thought
by some to be due to an excessive growth of the vascular
mesoblast. The acquired type has been explained by a stagna-
tion of blood, and congestion, which induce dilatation of the
vessels with atrophy of the intervening liver cells. Some increased
iibrosis takes place, so that a cavernous naevus is produced. This
view is supported by Chervinsky,* and also by Hanot and
•Gilbert.2
The ascites, the pain, and the size of the tumour are all
interesting features. The ascites possibly was accentuated by the
cirrhosis also present, and the veins noticed on the abdominal
wall would point to a portal obstruction that Vas not very recent.
The pain and failure soon after paracentesis are difficult to explain,
especially as the heart showed no signs of acute failure ; but the
feeble nature of the pulse, and the rapid reaccumulation of fluid
during the last few days, suggest a large amount of back pressure
from the right side of the heart, probably causing a more acute
dilatation of some of the more recently formed spaces. The size
of the tumour is remarkable, especially for the unencapsulated
form, in so old a subject. Mantle^ mentions a case in a man
aged 33, in which the liver weighed 6 lb. 13 oz., and the angioma
hung down eight inches below the anterior edge of the liver, and
was of the consistency of the placenta. The left lobe in this case
was normal, except for some dilated branches of the portal vein.
There was also small-celled infiltration and cirrhosis throughout,
but there was no bile in the urine, and only a few ounces of fluid
in the abdomen. The tumour was estimated to have contained
eight pints of blood, and was only diagnosed after exploratory
laparotomy, when a needle being put into the swelling blood
spurted out, and, in spite of suturing and plugging, the patient
died in two hours.
The diagnosis of such cases has usually only been made after
laparotomy or death, but the venous hum sometimes heard over
the liver area has been thought to be due to this cause. Hale
1 Arch, de PhysioL norm, et path., 1885, 3 s., vi. 553.
■^ Etudes sur les maladies du foie, 1888, p. 316.
a Brit. M. J., 1903. i. 365.
5
Vol. XXV. No. 95. n \
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50 DR. D. J. CHOWRY MUTHU
White® says angioma is common, but produces no symptoms
during life.
Surgical treatment by electrolysis is mentioned by Keen ^ as
having been performed in four cases, and Cripps has recently
removed a capsulated naevus of the liver, previously diagnosed
as an ossifying sarcoma, with success. In 1894 Tenedat refers to
only six cases in which excision has been carried out.
I am greatly indebted to Professor Walker Hall for laboratory
assistance, and for the suggestioaN-tojnvestigate the subject.
The accompanying ^lotp j^dph^ ^o^^b^how the cyst-like
spaces, &c., as explain^ aboveT^for the^Mu^o-photograph of
the section I am ind/bted Jp|-^*"-lJjftnriji5>ff2Lyl
THE SANATORIUM TREATMENT OF PULMONARY
TUBERCULOSIS— IS IT A SUCCESS?
D. J. Chowry Muthu, M.D.,
Physician, Mendip Hills Sanatorium, Wells.
Such a mass of literature has been written on pulmonary tuber-
culosis and its treatment, that I will not trouble the reader by
going over any unnecessary ground, but shall confine my remarks
to personal observations made during my eight years' connection
with the sanatorium treatment of consumption. The pioneers
of the open-air movement, most of whom are medical men belong-
ing to various sanatoria, have cause to be proud of the success of
their efforts in creating in this country a public interest in the
subject. The man in the street, encouraged by the early en-
thusiasts of the movement, expected that everyone entering the
portals of a sanatorium would be cured in a very short time.
And even medical men, without giving a due consideration to
the question, were led away by exaggerated reports, and pro-
^ AUbutt's System of Medicine, 1897, iv. 211.
■^ Ann. Surg., 1899, xxx. 276.
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ON PULMONARY TUBERCULOSIS. 51
claimed in private and in public that a few weeks' stay in an
open-air establishment would be sufficient to cure a consumptive
patient. The inevitable consequence was that the results fell
short of the public expectation, and discredit most unjustly fell
on the whole movement.
But what are the facts ? Speaking from my own experience,
I should say, to put it modestly, that in at least 50 per cent, of
cases life and health are restored by the open-air treatment.
That is, about half the patients of all stages that enter a sana-
torium either get well completely or their disease is arrested so
as to enable them to return to work.
To give a mere bald statement of figures, we have records of
one hundred and fifty patients treated in my sanatorium during
the first four years ending August, 1903. Of these, seventy-eight,
or about 51 per cent., have been restored to health, and are follow-
ing their various occupations to the present day. Surely this is
a record that any treatment can be proud of, and is worth striving
after.
The duration of the treatment has a very important bearing
on its success. It is utterly absurd to expect, as some have done,
to cure a patient or even arrest the disease in three months.
There is no doubt some truth in the insinuation that the patients
who have been partly patched up by the open-air treatment and
return to unhealthy surroundings relapse more quickly than
those who have remained in the old conditions of life, simply
because half a cure is worse than no cure. A creaking door lasts
longer if left alone, because everyone knows its deficiency and
uses it carefully ; but it looks strong when it is half mended and
painted, and the first careless knock breaks it to pieces. The
open-air cure is, I am sorry to say, long and tedious, requiring
infinite patience and perseverance on the part of the physician
and the patient. It is Nature's cure, and Nature builds well,
but slowly. The causes of failure of sanatorium treatment
are mainly due to : —
{a) Medical men not sending their cases at an early stage.
(b) Patients who at the first sign of return of health go home
thinking they are cured.
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52 DR. D. J. CHOWRY MUTHU
(c) Institutions which cannot keep patients for more than
two to four months, and then send them back to their
former unhygienic surroundings.
(d) Treating patients at home when no medical supervision
or discipline is possible.
The most important cause of failure in my experience is that
patients either have no means to continue the treatment for long,
or have not the patience to persevere in the sanatorium regime.
At the first sign of return of health they leave the sanatorium
and seek more congenial surroundings. Rigid discipline, cold,
absence from home and friends, &c., are unpalatable, and it is
most difficult to convince patients that health can only be got
back by great sacrifice, that Nature demands strict conformity
to her laws. It is one of the signs of this decadent age that
patients have not the strength of character or stamina to stand
fast and strenuously continue in the fight with the disease.
I go further, and say that the question of arrest of the disease
is more a matter of a patient's perseverance in the treatment than
even whether he comes under treatment at the first, second or
any stage of the disease. This may be a bold statement to make,
but nevertheless it is my experience. Over and over again I
have known patients who came to the sanatorium in the early
stage, and who returned home too soon, partly patched up,
with the result that after a few months they succumbed to the
disease. On the other hand, I have known others who came to be
treated in the cavity stage and with very little resisting power,
but who have persevered for two and three winters, and are living
now to testify to the efficacy of the open-air treatment. Of course
I exclude from the present consideration those cases which seem
to go wrong from the very beginning, and which get steadily
worse in spite of every care and attention. We do not understand
at present the laws that underlie these cases ; some day we shall.
I also exclude those cases of advanced stage, where gastric
functions are deranged, and the process of assimilation and
excretion is poisoned by toxins and other products of pathogenic
organisms. But apart from these cases, broadly speaking, the
failure or success of the treatment depends more or less upon the
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ON PULMONARY TUBERCULOSIS. 53
patient himself. In other words, the amount of vitality and
fighting force determine the prognosis of almost every case. The
sanatorium treatment increases the resisting force of the patient.
If he perseveres in the treatment, there is every probability of his
increasing his vital force and of overcoming the disease sooner or
later.
On the other hand, I foresee that the sanatorium treatment
will fail, because patients, from lack of time or means, from lack
of inclination or strenuousness, will desire to get well in a hurry,
and cannot. There is no short cut to Nature's cure ; she works
slowly, but surely. The earth takes just as long to go round the
sun as it did some hundreds of years ago, and it has found no
short road yet. Various remedies have been brought forward
from time to time and exploited as speedy cures for the disease,,
but they all have been failures so far. Nature cannot be tricked
to cure a patient in this way. She proceeds step by step, line
upon line, and health can only be regained by strictly adhering
to her laws ; and the result of perseverance is a sure and certain
success in many cases.
The success of the open-air movement is not merely to be
gauged by the number of lives it has been tlie means of saving,
but in a greater degree it is seen by the way in which it opens up
larger issues, and rouses the nation to see the evil tendencies of
modern thought and modern life, suggesting reforms along
national, social and municipal lines. Tuberculosis is one of the
evils of present-day civilisation. As long as there are crowded
centres like London, Manchester and Liverpool, which are breed-
ing-places for dirt and microbes, one can never hope to eradicate
consumption. It is like trying to bale out water from a ship
that has sprung a leak. As fast, or faster than you can pump,
the water rushes in through the hole and fills the ship. As fast
as you can cure patients, their places are filled up by others
manufactured by the crowded and dirty towns.
Besides, tuberculosis goes hand in hand with other evil factors
in the vicious circle, viz. competition, overcrowding, poverty,
drink, a life of bustle and excitement, all of which tend to keep
man at high tension and irritation, giving him no time for the
Digitized by VjOOQIC
54 DR. CHARLES REINHARDT
recuperation of vital forces, which are necessary for the main-
tenance of his health. Nature not only needs time to build, but
also rest and quiet to do her work. In silence she manufactures
in her secret laboratories the vital energies required to maintain
life's functions and duties. Mere giving attention to sanitation,
or building large sanatoria for consumption, is like sprinkling
carbolic powder over the leakage of drain pipes. The sanatorium
treatment is only a part of a great movement which aims at
going to the root of the matter. Like the ever-widening circles
caused by a stone dropped into a still lake, it tends to widen the
outlook and extend its reforms from one disease to the prevention
of all disease, and never rests till it has taught the nation to regard
the health of its ckizens as a sacred heritage, which it should
guard at all costs and against all enemies. Looking thus from a
broad point of view, the sanatorium treatment can never be
regarded as a failure.
SOME NOTES ON STYRACOL.
BY
Charles Reinhardt, M.D.
For several years after having established the Hailey Open-air
Sanatorium for consumption on the Chiltern Hills in Oxfordshire,
it was my principle to avoid the administration of drugs so far as
possible, and, indeed, medicines were seldom employed excepting
for special emergencies.
Nothing has happened to convince me that in ordinary cases
of phthisis medicinal treatment in the form of drugs administered
internally is of any pronounced advantage amongst patients
undergoing the open-air treatment in a sanatorium. I am even
inclined to the opinion that those who suffer from incidental
troubles, such as dyspepsia, diarrhoea, or cough, are as a rule likely
to do quite as well if drugs are withheld, excepting in unusual
cases. There is, however, one medicament of which I was forced
to make an exception on account of the benefit derived by patients
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SOME NOTES ON STYRACOL. 55
from its use, and that is guaiacol, which in my opinion is one of
the most useful of drugs in the treatment of phthisis.
I was first obliged to arrive at this conclusion owing to an
involuntary experiment. A patient — W. D. — arrived at the
institution suffering from extensive cavitation of the left lung,
both lobes of which were involved, the right lung being apparently
free. The case was a chronic one, and had been under treatment
at several other sanatoria. There was a moderate amount of
cough and expectoration, but the temperature was normal, and
I was able to give a fairly good prognosis. The patient had been
taking guaiacol regularly, but on my advice this was at once
discontinued.
It often happens that patients entering an open-air sanatorium
make rapid and immediate progress, the symptoms abating and
an increase of comfort and of vigour being experienced. This
reaction is, of course, gratifying, even though the rate of progress
is not always maintained. In the case to which reference is being
made, however, the reaction or early access of improvement did
not occur, to the disappointment both of the patient and myself,
and for some time the condition of the former remained almost
stationary, though there was a slight increase in the amount of
cough, and an undoubted increase in the rales at the apex of the
right lung. There was also some amount of diarrhoea. I attri-
buted the want of apparent benefit partly to the chronicity of the
case and the fact that the patient was in no sense new to sana-
torium life, and partly to a certain boisterousness and excitability
of temperament which he displayed. He, however, insisted that
his progress had ceased when he gave up his diurnal doses of
guaiacol. After six weeks had elapsed without noticeable benefit,
a sudden improvement commenced, and it went on without
interruption. Some time afterwards I found him in the act of
taking a dose of guaiacol, and to my surprise he told me that he
had recommenced the regular use of this drug six weeks after
admission, which corresponded to the date when the improvement
commenced.
I then sanctioned the use of the guaiacol, or rather replaced it
by styracol, which I knew to be a combination of guaiacol and
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56 SOME NOTES ON STYRACOL.
cinnamic acid, free from some of the disadvantages of guaiacol,.
and I was pleased to find that the patient continued to make
progress as long as he remained in my sanatorium. He never
again suffered from diarrhoea, but he eventually made a good
recovery, is now married and in good health.
This case led me to employ guaiacol, chiefly in the form of
styracol, in a number of instances, almost always with encouraging
results ; but owing to the unpleasantness of the creosote-like
flavour of guaiacol and to the tastelessness of styracol, and the
fact that the latter only splits up into its components, guaiacol
and cinnamic acid, when it has passed through the pylorus, I soon
came to favour styracol, and to discard the use of guaiacol.
In all cases in which I suspected intestinal tuberculosis, or in
which there was anything more than accidental diarrhoea, I
administered styracol, and nearly always with advantage.
I also employed it in cases in which there was much cough,
expectoration, or moisture in the lung, and I generally found
these conditions were improved by its use.
In one instance, a patient suffering from a very large cavity
occupying a considerable portion of the upper lobe of the right
lung, was troubled with an extremely offensive expectoration,
and a foetor of breath which I was quite unable to assuage. The
administration of styracol, however, eventually succeeded in
reducing these unpleasant conditions to a remarkable extent,
and if the dosage was omitted for any length of time they soon
returned, though not quite to the same extent as before.
I have never found any ill effects follow the exhibition of
styracol, and I have found benefits which were quite in excess of
those following the administration of guaiacol in similar cases.
This may be attributable to the therapeutic effects of the cinnamic
acid, which is one of the components of styracol.
I have employed styracol in the form of powder and that of
tablets. In the latter case I always recommended patients to
bite them into minute particles, in order to secure that they
should not pass through the alimentary system unchanged. The
act of masticating styracol is not unpleasant, as the tablets are
practically tasteless.
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MEDICINE. 57
In my opinion styracol is one of the best available intestinal
antiseptics, and its continual exhibition seems to impregnate the
organism with guaiacol, so that the beneficial influence of that
drug upon lung tissue undergoing necrosis is exerted to the full.
IProGre00 of tbe flDeMcal Sciences.
MEDICINE.
On the blood-glands as pathogenic factors in the production
of diabetes. — Lorand/ in a paper on this subject, points out that
a certain antagonism exists between diabetes and tuberculosis
in so far that tuberculous people rarely become diabetic or gouty,
although diabetic patients may become tubercular. Conditions
which are associated with thyroid deficiency seem to possess a
certain immunity to gout and diabetes. Bayon, of Wurtzburg,*-
and de Querrain have carried out researches which show that in
all grave infectious diseases the thyroid is in a condition termed
by them " thyroiditis simplex. '* Roger and Garnier^ had
previously demonstrated the hypersecretion of the thyroid in
infectious diseases, which hypersecretion in its turn might be
followed by exhaustion. In many infectious diseases symptoms
arise which indicate an increase in the function of the thyroid,
such as hyperthermia, tachycardia, slight exophthalmos, per-
spiration, and occasionally diarrhoea and diuresis. Those who-
inherit a good working thyroid will have a greater immunity
against infectious diseases than others. Children who become
diabetic are, as a rule, of bright intelligence, a symptom attributed
by the author to a condition of hyperthyroidea, in contrast to the
mental torpor met with in conditions of athyroidea. The sexual
glands are in close relationship with the other blood -glands,
especially the thyroid, which frequently shows enlargement from
overfunction, as in repeated pregnancy, prolonged lactation, &c.
This overfunction may be followed by exhaustion leading to
myxcedema. The islands of Langerhans, like the parathyroids
and adrenals, also represent blood-glands. The ordinary secreting
tissue of the pancreas may be destroyed by cirrhosis without any
involvement of the islands, as in an example in the Vienna Patho-
logical Institute, in which case there was no diabetes. The
author, however, considers that the absence of any pathological
change in the islands of Langerhans after death in cases of diabetes
may be explained by defective functionating properties of the
^ A. Lorand (Carlsbad), Tr. Path. Soc. Lond., 1906, Ivii. i.
2 Wurzburger Abhandlungen, 1904. ^ Presse m^d., 1899.
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58 PROGRESS OF THE MEDICAL SCIENCES.
cells, the nervous tract to the pancreas possibly being involved ;
for, as he points out, Pawlow has demonstrated in the dog that
there exists not only a psychic gastric juice, but also a psychic
pancreatic juice. Sobolew found that in animals the islands
diminish in size after the administration of rich carbohydrate
food, a fact which may explain why diabetes may occur more
readily in those who for a long time have been on carbohydrate
diet. The various blood-glands stand in close relationship one
with another, changes in one being followed by changes in others.
In acromegaly diabetes is frequent. In this disease the author
maintains that the thyroid is altered even more frequently than
the hypophysis. The changes in the latter gland he regards as
secondary to those in the former. He has shown that diabetes
only occurs in those cases of acromegaly which show symptoms
•of hyperthyroidea. While on the one hand certain blood-glands
are found degenerated in diabetes, on the other the extracts of
•other blood-glands may produce glycosuria or diabetes. Thus
the injection of adrenal extract may produce considerable glyco-
suria. The extract of thyroid may produce even in a higher
degree than adrenal extract considerable glycosuria, and even
true diabetes. According to Naunyn. Van Noorden and Strauss,
diabetes only follows in such cases where there is inherited pre-
disposition. All the symptoms of the diabetes may, however,
be produced by the administration of thyroid extract. In a
patient suffering from acromegaly to whom the author adminis-
tered thyroid tablets, glycosuria associated with the excretion of
diacetic acid and acetone had existed for eight years. Before the
administration of thyroid he had no glycosuria. There is an
unusual tendency to alimentary glycosuria in ordinary cases
of Graves's disease, although it is rare in those cases which are
passing into a condition of myxoedema. In those cases in which
diabetes has been noted in myxoedema it has apparently been
produced by treatment with large doses of thyroid extract. The
glycosuria of infectious diseases, and that after mental emotions,
is probably related to the condition of hyperthyroidea set up in
these states. Similarly, the increase of glycosuria during men-
struation, and the lactosuria of lactation are also probably related
to hyperthyroidea. Further, Hurthle has demonstrated that
stagnation of bile causes an increase of thyroid colloid, and Gans,
Finkler and Exuer have found glycosuria during biliary colic.
It is an interesting fact that after thyroidectomy in the goat the
milk becomes poor in sugar but rich in fats. The diminution of
glycosuria before death in opium poisoning, its rarity in chronic
tuberculosis and cancer the author attributes to a diminution of
thyroid secretion in these conditions. There have been cases of
diabetes in which the sugar has disappeared after the onset of
tuberculosis. The auther has observed enlargement of the
^ Deutsche med. Wchnschr., 1897, No. 12.
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MEDICINE. 59
thyroid in cases of diabetes, although he does not regard this as
necessarily proving overaction of the gland. On examining the
thyroid of three dogs in the laboratory of Prof. Minskowsky, of
Cologne, after removal of the pancreas, he found much enlarge-
ment of the vesicles and much colloid material. The changes in
the thyroid of these dogs very much resembled the changes pro-
duced in the thyroids of fowls after meat feeding by Chalmers
Watson.^ In the early stages of Graves's disease similar changes
are found in the thyroid. In Graves's disease the increased secre-
tion constitutes a toxic agent, causing, as shown by Magnus-Levy,
a decomposition of albuminous substances. This decomposition
leads to the splitting off of the carbohydrate radicle, the existence
of which in the albuminous molecule has been demonstrated by
Pavy.-
If under these circumstances the pancreas happens to be in
any way degenerate, sugar appears in the urine. As an example of
this, in the wards of Van Noorden was a case of Graves's disease
in which after a few years diabetes developed. After death calculi
were found in the pancreatic duct, and the gland tissue itself was
degenerated. The author concludes that there are two important
factors in diabetes : (i) degeneration of the pancreas ; (2)
hyperactivity of the thyroid. If the pancreas alone is degenerated
the diabetes will be a light one, as in the diabetes of old people due
to arterio sclerosis of the pancreas, without any corresponding
hyperactivity of the thyroid, for, as pointed out by Victor Horsley,
the thyroid undergoes degenerative changes in old age. In young
people the diabetes is more severe, because their thyroids are in
good working order. The author considers that antithyroidin
serum is capable of diminishing glycosuria, though he does not
advocate its use in advanced cases. Diabetes will more readily
occur in persons who take much meat, especially if they take
large quantities of carbohydrates. Chalmers Watson has recently
shown experimentally that an increased activity of the thyroid
follows a meat diet.
The acetone bodies. — Diacetic acid is so readily decomposed
into acetone and carbonic acid, that no satisfactory method has
been devised of separating the acetone and diacetic acid quanti-
tatively in the urine. B-oxybutyric acid can, however, be
separately estimated. While small amounts of acetone may be
found in the urine of comparatively healthy individuals, the
^excretion of B-oxybutyric acid and diacetic acid are invariably
due to pathological conditions. According to Schwartz, as
much as 70% of the acetone which is excreted in pathological
states may be excreted by the breath, while Geelmuyden has
estimated that 80 — 95% may be lost through the lungs. There
1 Lancet, 1905, i. 347 etseq. ^ Pavy, Physiology of Carbohydrates, 1894.
* "The Acetone Bodies: their Occurrence and Significance in Diabetes
and other conditions," T. Stuart Hart, Am. J. M. Sc, 1906, cxxxii.
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6o PROGRESS OF THE MEDICAL SCIENCES.
is no constant ratio between the amount of acetone which is
excreted by the kidneys and that excreted by the lungs. The
acetone bodies are formed in considerable quantities in digestive
disturbances and in febrile diseases. Certain drugs increase
acetone production, including benzol, antipyrin, morphine and
heroin. Nervous shock and excitement have been shown
experimentally to lead to an increase of excretion of acetone
bodies. An effort has been made, unsuccessfully however, to
find out the particular organ of the body in which the acetone
bodies are manufactured. In no organ, however, has acetone
been found in larger amount than could be brought to it by the
circulating blood. In the laboratory the acetone bodies have
been derived from proteids, carbohydrates and fats. Almost
certainly in the body an abnormal destruction of fat is the main
source of acetone body formation. The amount of proteid
destruction as represented by the output of nitrogen, phosphates
and sulphates, and the amount of the acetone bodies excreted are
not parallel either in diabetes or starvation. Magnus-Levy has
reported a case in which there was a metabolism of 262 grammes
of proteid in three days, and yet this patient excreted 342 grammes
of B-oxybutyric acid in this period, which was more than could
have been derived from the proteid. The withdrawal of carbo-
hydrates from the diet of a normal man almost always results in
an increase of acetone excretion, while the administration of
carbohydrates has the opposite result. In some cases of diabetes
the amount of B-oxybutyric acid varied directly with the amount
of fat in the food. Large quantities of fat administered to
healthy people in a mixed diet increase the excretion of acetone.
An abnormal amount of acetonuria is not produced in starvation
merely by diminishing the caloric value of the food. For example,
a diet consisting of 1.4 litres of beer with 750 grammes of bread
gave rise to no acetonuria. On the other hand, a pure proteid
diet in a healthy man may cause considerable acetonuria, in
which case the acetone is probably derived from the breaking
down of the body fat. A pure fat diet may produce more ace-
tonuria than starvation, the acetone in this case being derived
both from the body and food fats. The amount of the acetone
excretion depends to some extent on the character of the fat used.
Addition of carbohydrate to any of the foregoing diets diminishes
the acetone output. This reduction is exceedingly rapid, indicat-
ing that the first effect must be to furnish the conditions necessary
for the complete oxidation of the acetone bodies at that time
circulating in the blood. There is no parallelism between the
excretion of sugar and the acetone bodies in diabetes. In this
disease the main source of the acetone bodies is the imperfect
metabolism of fat, which may be either the body or the food fat.
As in health, the addition of carbohydrate to the diet generally
results in a diminution of the acetone output, while its with-
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SURGERY. 6l
drawal may increase the acetone excretion. However, in
advanced cases there may be exceptions to this statement. Fat
feeding appears to be a frequent cause of the increase of acetone
bodies. Fever in the diabetic usually reduces the output of
sugar, while it increases that of the acetone bodies. The loss of
power of oxidation in the diabetic has been shown by Waldvogel,
who injected B-oxybutyric acid subcutaneously in cases of mild
diabetes, and found that the resulting acetonuria was considerably
greater than in his control experiments in healthy men. In
coma, while B-oxybutyric acid is always present, acetone and
diacetic acid may be relatively diminished, and sugar may be
absent. The author considers that diabetes should be regarded
as a disease in which there is a failure of the organism not only to
utilise carbohydrates, but also to utilise fats. He believes that
the disorders of fat metabolism are more than a secondary result
of the diabetic's inability to assimilate carbohydrates, and that
there is a direct perversion of the metabolism of fat. From the
therapeutical aspect, since nervous irritation, excitement, hunger
and fever all favour the production of the acetone bodies, they
should as far as possible be avoided. Similarly, general anaes-
thetics should be avoided, and, if absolutely necessary, the
starvation before and after should be a minimum. The with-
drawal of carbohydrates should be carried out gradually, and* the
amount of fat which can be used without setting up acetonuria
should be carefully watched. In selecting fatty foods, those
containing the higher fatty acids should be chosen, since those
containing the lower acids increase more markedly the production
of the acetone bodies. If in spite of these precautions diacetic
acid and B-oxybutyric acid are found, we must resort to the
administration of alkahes. Simon, of Carlsbad,* has met with
success in removing acetonuria in three cases by giving Parmesan
cheese in amounts up to 3J ounces daily. He recommends this
cheese in cases where the exclusion of fats, particularly butter,
nas been unsuccessful in relieving this condition.
J. R. Charles.
SURGERY.
Bier's method of treating tubercular joints by the production
of passive hyper aemia can hardly be described as a new subject,
inasmuch as it has found a place in current text-books for the
last ten years. But owing to the fact that the treatment was
long and tedious, it was never received with much enthusiasm
in this country, and it probably never received the trial that it
deserved. But during the past year Professor Bier has com-
municated to the German Surgical Congress, and also to the
1 "Treatment of Acetonuria of Diabetes by the Ingestion of Parmesan
Cheese," La Semaine mfid., 1905, No. ^6.
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62 PROGRESS OF THE MEDICAL SCIENCES
Miinchener medicinische Wochenschrift,^ a very much extended
scope for this treatment, viz. to all forms of acute inflammation,
and already in Germany and America other surgeons who have
tried it declare that it is of very great value.
During the past thirty years the attention of surgeons has
been so much occupied with the elaboration of the principles
discovered by Lord Lister, and of the operations that these anti-
septic principles have made possible, that every other method of
treatment has been regarded as of little importance. The
prevention of infection and of suppuration has claimed so much
attention, that the treatment of infected or inflamed tissues has
been very little thought of. Of course, nothing can ever supersede
the importance of preventing infection and suppuration of tissues,,
but, nevertheless, such infection will always occur, and it is a
matter of great importance if any method can cut short the
process and minimise its evil results. Now this is what is claimed
for the method of artificial hyperaemia. As opposed, to the old
anti-phlogistic school, who regarded all inflammation as bad and
hurtful. Bier's view is that inflammation is the natural cure of
infection, and therefore should be encouraged. But although
the principle underlying its application to tubercular and to
inflammatory cases is no doubt the same, the method of its appli-
cation is so different in the two classes of case that it will simplify
matters if they are described separately.
In the case of tubercular joints, artificial congestion has been
applied successfully*^ to all except the hip. A rubber bandage
is wound round the limb at as great a distance from the joint as
possible, and over a layer of gauze. In the case of the shoulder,
the bandage is kept in place by calico strips round the neck and
round the chest. The amount of constriction to be applied is a
matter of great importance. The arterial supply as estimated
by the pulse should not be altered, but the veins so compressed
that the return of blood is hindered, and a congestion occurs below
the bandage. The temperature of the part should be raised and
not diminished. The bandage remains in its place for one to two
hours daily, and the treatment of a case of moderate severity
occupies from four to six months. If the bandage be left on too
long in these cases acute inflammation is apt to supervene, and
suppuration occur, and it is very important to bear this in mind
in distinguishing between the treatment of tubercular and acute
inflammatory cases.
It is not the primary object of this paper to deal with the
tubercular cases, but in order to give completeness to the subject
it may be well to briefly mention some recent publications which
indicate the results of passive congestion as applied for these
* Munchen. med. Wchnschr., 1905, lii. 201, 263, 318 ; also Bier's
"Hyperamie als Heilmittel," 1905.
* Lancet, 1905, i. 1091,
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SURGERY. 63:
conditions. Habs^ gives an account of 200 tubercular joint
cases in which he used this method. Whilst all varieties of the
disease may show improvement, yet he recognises certain well-
marked differences in various groups of cases. Thus children
react much better than adults. Mild chronic cases do better than
acute ones. Cases of pure synovial disease, when there is no
affection of the bones, are those in which the results of the con-
gestive method are the best. The elbow, wrist, knee and ankle
all give good results, but the shoulder has also been successfully
dealt with. Now it is evident from these observations that Bier's
method is of the greatest value in just those cases which would in
any case be treated by expectant rather than operative measures.
Therefore it is ' not so much a question of choosing between
operation or passive hyperaemia, as of simply adding the con-
gestive treatment to other methods of non-operative procedure.
In the knee, however, although the cases may improve for a time,,
a large proportion ultimately require operation. In early cases
of wrist and ankle disease the method is of particular value,
because it is in these that mere immobilisation so often fails. In
fact, Bier - recommends that in early cases the joints should not
be kept at rest, but that passive movements, preferably carried
out in a hot-water bath, should be regularly employed. Tuber-
cular cases in which the skin is broken or in which there is any
septic complication, are not suited for the treatment, for although
artificial congestion is used both for septic and tubercular affec-
tions, it has to be applied in a different manner in each case, and
therefore cannot be employed when the two conditions co-exist..
UUmann"^ reports three cases of tuberculous testes successfully
treated by Bier's method. A rubber band was bound lightly
round the base of the penis and scrotum for half to one hour daily..
In these cases the tuberculous disease had infiltrated the skin,,
and in all of them the pain and discharge were lessened, and the
tubercular infiltration became smaller and softer, whilst the
patients gained in weight. One would like to know the further
history of these cases. Polyak^ has tried the method with most
gratifying results for tuberculosis of the larynx. The rubber
band is applied as low down in the neck as possible, but quite
lightly so as not to cause any inconvenience to breathing. The
relief of pain is said to be the first and most striking result, and
is the safest criterion of the amount of good which is likely to be
gained by persisting in the treatment.
But it is the application of artificial congestion to acute in-
flammatory lesions of all kinds, e.g. a whitlow, a carbuncle,
osteomyehtis or suppurative mastoiditis, that constitutes the more
recent chapter in the history of surgical progress. Bier himself
^ Miinchen. med. Wchnschr., 1903, 1. 938 ; abstract in Edinh. M. J.^
1903, N.S., xiv. 359.
Lancet, 1905, ii. 1737. ^ Edinh, M. /., 1906, n.s., xx. 183.
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•64 PROGRESS OF THE MEDICAL SCIENCES.
began to apply his method in such cases as long ago as 1893, but
it was only last year that his work was fully published, and his
results corroborated by other observers.
In these cases the actual constricting agent is applied in the
same way as above described, but it is allowed to remain in
position for very much longer, that is to say for 20 to 22 hours
out of the 24 For such a condition as a whitlow in the hand,
the bandage is applied to the upper arm, for inflammation of the
foot it is applied to the lower part of the thigh. Again, in striking
■contrast to the best conditions in tubercular cases is the fact that
the more acute the inflammatory lesion is, the better result does
the congestive treatment give. The pressure of the band should
be very light, but soon after its application the limb becomes a
fiery red, which spreads from the original focus right up to the
bandage itself. Then, too, the whole becomes swollen and
•oedematous, and if any incisions exist they pour with serous
-exudation. The position of the bandage is changed every ten
hours, and in the short intervals between the periods of constric-
tion the limb is raised to favour absorption of the oedema.
As soon as the congestive reaction has set in the patient feels
a great relief of pain, the pulse becomes slower and more regular,
and the temperature falls. The temperature rises, however,
between the periods of constriction, but this, which is marked at
first, soon becomes much less, until in about three to six days a
normal mean is maintained. If suppuration occurs the pus must
be let out, but the incisions need not be so free as would ordinarily
ibe the case. Of course, if septicaemia or pyaemia has already
developed this treatment is of no avail, except in hastening the
resolution of any particular focus. Cathcart ^ gives a summary
of Bier*s recent papers with some of his cases, and adds a number
of his own personal observations at the Edinburgh Infirmary.
The scope of the method is well shown by the following typical
examples of large groups of cases.
Suppression of commencing suppuration, — On April 8th, 1904, the
left wrist of a woman of 60, who had a septic wound of the breast,
became inflamed, with a rigor and temperature rising to 103° F.
Passive congestion applied for 20 hours daily cured the condition
in three days, the pain, heat and raised temperature disappearing.
Transformation of acute into cold abscess. — ^This is a rare
occurrence. A boy of 7 was admitted on July 28th with an acute
abscess in the lower end of his thigh. An exploratory syringe
drew off thick pus containing staphylococci. Under passive
congestion the inflammation had gone by July 30th, and the
raised temperature fell to normal. The abscess remained as a
•cold, fluctuating swelling. On August 5th a i cm. long incision
was made into it, and the pus pressed out without further opening.
Jt healed by August 9th. This transformation of acute into
^ Scottish M. and S. J., 1906, xviii. 302.
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SURGERY. 65
chronic abscesses is not, however, to be waited for or expected
as a routine. It is better to open abscesses at the time the con-
;gestion is first applied.
Suppurating surfaces. — In these the pus at first becomes more
abundant, but thinner. Very shortly the pus ceases, sloughs are
thrown off, and other parts recover which would have necrosed
under ordinary treatment. And the suppurating process becomes
•definitely limited, instead of spreading. Inflamed joints and all
kinds of arthritis have been successfully treated, but the more
acute cases seem to show more brilliant results than the chronic
ones, e.g. osteoarthritis. In joints containing pus only a diag-
nostic puncture is made, but the joint is neither opened nor
-drained. The part is kept at rest, but the joint is not immobilised,
but, on the contrary, is subjected to gentle passive movement as
soon as the passive congestion has produced a cessation of pain.
A man of 18 was admitted seventeen days after a septic wound
which had penetrated the left elbow-joint. The joint was red,
swollen, painful, and fixed at a right angle, and pus could be
squeezed plentifully from the wound. In three weeks' congestive
treatment the joint had recovered and the fistula healed. Within
another month he had a freely movable joint. A man aged- 20
was admitted with acute suppuration in his right knee, the origin
•of which was unknown. All the typical signs of acute suppurative
arthritis were present, including rigor and a high temperature.
The syringe withdrew pus containing living staphylococci. After
twelve days' treatment the temperature was normal, the swelling
was less, the pain had ceased, and the patient could flex his knee
to a right angle. The fluid in the knee was now turbid serum. He
recovered the complete use of the knee-joint, so that he was taken
as ward attendant at the clinic.
Suppuration in tendon sheaths. — In these cases it is important
to make incisions directly pus is formed, but these need only be
stab incisions, and no packing or draining is required. Pus pours
from them readily enough when congestion is applied. A butcher
of 43 had a wound of the little finger which had infected the tendon
sheaths and cellular tissue up to the elbow with acute lymphan-
gitis. Temperature was 102.1° F., and he was very ill. After
four days' treatment all the local inflammation had gone, the
temperature was normal, and after a few tendon sloughs had
•escaped the wounds healed, and he had good use in his hand
except for a little stiffness of the finger. Out of 22 cases of tendon
sheath suppuration, 14 recovered without sloughing. And the
•extraordinary and almost incredible rapidity of the cures are in
marked contrast to the tedious course of such cases when treated
by the old methods.
Acute osteomyelitis. — Bier has had 14 cases of acute osteo-
myelitis, of which 6 recovered with no necrosis, 5 with very little
necrosis, 2 with extensive necrosis, and i died of pyaemia.
6
Vol. XXV. No. 95.
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66 PROGRESS OF THE MEDICAL SCIENCES.
Gonorrheal arthritis. — A married woman of 38, who had been
infected with gonorrhoea some time previously, was attacked by
typical acute arthritis of the right knee-joint. For a month rest^
extension, fomentation and drugs were tried without avail, but
within fifteen minutes of the application of the rubber bandage to
the thigh the pain was easier, and in a few weeks she was able to
walk about with a somewhat stiff knee.
Of course, in many cases disappointment follows the method,
as in these it proves inefficacious, but if carefully applied to suit-
able tases it does not do harm, and with practice and experience
its scope will greatly increase.
Besides the elastic bandage, various kinds of suction apparatus
may be used, and Dr. Klapp, Professor Bier's assistant, has
devised a number for use in different positions of the body. For
example, in the case of acute mastoid disease a suction cup may
be placed over the mastoid region, in addition to or instead of a
band round the neck.^ Bier states that if this is done, only a
small puncture into the mastoid antrum is necessary, and the case
quickly recovers with good functional results in 60 per cent, of his
cases. Polyak- has used a suction cup for tonsillar and pharyngeal
inflammation, but finds that a band low down in the neck will
give great relief to such diverse conditions as nasal catarrh,
pharyngitis, maxillary suppuration, or laryngitis. Rudolph*
has devised a suction apparatus which can be applied to the
cervix for inflammatory conditions of the uterus, and he reports
very good results from its use.
Whilst the majority of observers are agreed as to the
wonderful results obtained by passive congestion, yet there
are some who have not had such good results. Bardenheuer,
who is now a firm believer in the method, had very bad
results from it until he was instructed in its method of appli-
cation by one of Bier's assistants. Lexer* declares it to be
merely ** a game of chance " as to whether the inflammatory
processes will be checked or spread by its use, and he states that
he has found that it produces an extension rather than a limitation
of suppuration in cases where the parts are unopened. But if
incisions are made first, then even this observer admits the great
value of the congestion. Stettiner^ points out how suppurating
cavities and sinuses with small mouths may be made to heal
without enlargement by suction hyperaemia. This is of great
value in treating abdominal fistulas or stitch abscesses. Sick*^
remarks, and other observers, including Bier himself, agree with
him, that there are certain well-marked groups of cases in which
the treatment should not be applied, because in them it is likely
to do positive harm. These are : — Rapidly-spreading strepto-
^ Ann. Surg., 1906, xliv. 729. ^ Loc. cit.
** Centralhl. f. Gyn^k., 1905, xxix. 1185. ^ Ann. Surg., 1906, xliv. 731.
^ Ibid., p. 734. « Ibid., p. 730. .
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PATHOLOGY. 6/
coccal infections, including erysipelas, inflammatory lesions in
diabetes, varicose or congestive ulcers, and thrombo-phlebitis.
As to the mode of action of this treatment, we know little or
nothing. The very rapid relief of pain, occurring generally in a
few minutes to half an hour, must have a mechanical explanation,
and Bier suggests that it is due to anaesthesia produced by the
rapid oedema. The great effusion from the vessels of the part
must flood the inflamed tissues with serum, leucocytes and
opsonins, and it is possible that in this manner the invasion by
micro-organisms is overcome. But in inflammation which results
from chemical irritants the method is equally successful. It is
of value in this connection to note the experiments of Perthes,^
who injected strychnine solutions into animals' limbs, and found
that by the use of a constricting band the supervension of toxic
symptoms could be prevented, or so much delayed that the
animal would survive a dose which would have killed it if it had
been delivered into the free circulation. At any rate, it is im-
possible to rise from a perusal of the recent writings on this
subject by so many different authors without feeling that a great
addition has been made to our methods of treating common forms
of disease. And it certainly involves the necessity of our making
a personal study of the question, so that our patients may not be
deprived of what may be a most valuable aid to recovery.
E. W. Hey Groves.
PATHOLOGY.
The Pathology of to-day falls easily into three great divisions
— ^morbid anatomy, bacteriology, and chemical pathology. The
morbid anatomist is the one faithful to old traditions, belonging
to the cave-dwellers who see things dimly while lingering
over the minutiae of dead bones and tissues ; the bacteriologist
is the adventurer who leaves old memories behind and soars into
the unknown ether on the gossamer wings of Ehrlichism ; the
pathological chemist is the pacemaker who, while unravelling the
constitution of substances, provides the necessary armament for
the morbid anatomist and the chemical details for the bacterio-
logist. May a fourth class be added — the clinical pathologist,
that rara avis who sometimes exchanges the coat of the laboratory
for the plumes of the consultant !
Convulsions. — Mcllraith"^ has just concluded an examination
of 250 cases of convulsions occurring in infancy and childhood.
He finds that predisposing causes play a more important part
than do the exciting causes. The chief predisposing causes are
" an inherited neurotic taint," and rickets. The chief exciting
causes are those connected with gastro-intestinal disorders.
Convulsions are by no means as frequent as generally supposed
^ Ibid., p. 732. * Medical Chronicle, 1906-7.
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68 PROGRESS OF THE MEDICAL SCIENCES.
at the onset of acute fevers, such as measles and pneumonia.
They are more common at the onset of pneumonia than at the
•onset of measles.
In children suffering from convulsions there is frequently a
history of ill-health or disease in the parents, especially in the
mother during pregnancy, and this acts by lowering the vitality
•of the child and rendering it more liable to disease.
Only in a very small proportion of cases convulsions can be
ascribed to injury at birth, or to organic disease of the brain. In
€arly life convulsions may be the first sign of epilepsy, or may
give rise to that condition in later life, but distinct epilepsy is
more likely to supervene when there is no obvious cause for the
•early convulsive attacks.
Dentition is rarely a cause of convulsions, and only when some
predisposing cause exists. Cherchez Vintestin appears to be a
golden rule for infantile convulsions.
Tumours. — ^Among the countless hypotheses which, like the
many airships, rise only to fall again, the relation of trauma to
the site and aetiology of sarcomatous changes has been strongly
advocated by a number of recent writers. *' Ohne trauma, ohne
sarcoma *' is the utterance of one enthusiast. Many clinicians
could cite cases which appear to support this contention. The
point of view depends on the interpretation of the word '* trauma."
Hardly a day passes without the occurrence of knocks — ^physical
or mental — and imagination frequently aids the note-taker.
Nevertheless, though the idea will rapidly receive its quietus from
writers sufficiently vigorous to talk it down, yet there is much in
it. Incidentally, Sternberg has just published his work on
Trauma in Internal Diseases, and we are again reminded that
pathological changes are not concluded when the scar tissue
covers over the external wound. Whether it be lung, liver,
kidney, or bones, the seat of once damaged tissues must always
be regarded with suspicion. There is ever the possibility of
growth, or malnutrition, to think of in connection with an injury.
Fceces.^ — ^The clinician looks always at the faeces — preferably
through a telescope or the glass wall of a closed vessel — and his
assiduity is sometimes rewarded by the observation of unusual
appearances. Diagnosis may frequently be assisted by more
systematic investigations. Here are a few points culled from
several recent papers on the subject.
The insufficiency of the functions of the stomach are best
gauged by the amount of connective tissue in the faeces.
The extent of the deficiency of pancreatic digestion may be
determined by the amount of nuclein in the faeces. This should
be supplemented by estimations of the fat, but in itself is a very
useful sign.
Pancreon is a preparation of pancreas tissue. If steatorrhcea
^ Centralbl. /. Allge, Path,, 1906.
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or azotorrhoea disappear after its administration, then it is
probable that pancreatic functions are suspended.
Tuberculosis. — Many recent works ^ have been directed to the
paths of the infection in tuberculosis. It is declared that the
chief avenues are via the bronchi by inhalation, and the pharynx
by swallowing. The tubercle bacilli readily passes through
mucous membranes without leaving any evidence of its passage.
Schlossman affirms that tuberculosis is, in the greater number
of cases, a disease of childhood. Infection may occur by means of
tuberculous food, but this is a rare occurrence compared with
that of irifection from man. The child inhales air containing
tubercle bacilli, or touches infected material with the finger, and„
placing the latter in the mouth, is thereby contaminated. As
many as fifty per cent, of adults show signs of tuberculosis before
they are fully developed. The mortality amongst children is very
great, and the fight against infection of children through parents
and relations is a field which offers a prospect of great success in
not only reducing the child mortality from tuberculosis, but also
in reducing the numbers of those adults whose latent, oft-times
unsuspected tuberculous conditions are a source of danger to the
community, as well as a death-warrant to themselves.
I. Walker Hall.
IRcvicwg of Boohs-
A Guide to Diseases of the Nose and Throat, and their Treatment.
By Charles A. Parker, F.R.C.S. Edin. Pp. xiv., 624.
Illustrated. Edwin Arnold. 1906.
A very practical exposition of diseases of the nose and throat,
and their treatment by methods advocated at the Golden
Square Throat Hospital, founded on lectures delivered at that
hospital, has been written by a surgeon whose experience enables
him to speak with authority, and this volume is sure to prove
very valuable to all practitioners and students. It is clearly
written, well illustrated, and well printed, although amongst the
iUustratiotts many will be recognised as old acquaintances, and
some are distinctly poor, and not worthy of a modern text-book.
Throughout the book the numerous formulae for local pigments,,
sprays and applications will be found of service in practice.
The very clear and detailed description of most of the technical
methods now very frequently adopted by English laryngologists
must prove helpful to those whose earlier studies of the speciality
require to be kept abreast of the times, and hardly any page can
he read by such without gleaning some point of value.
^ "Reports of Hague Congress for Tuberculosis," 1906, in Centralbl. f,
Allge. Path., 1906.
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Indications for Operation in Disease of the Internal Organs.
By Professor Hermann Schlesinger, M.D. Authorised
English Translation by Keith W. Monsarrat, M.B.,
F,R.C.S. Pp. XV., 498. Bristol: John Wright and Co.
1906.
This book is written essentially for the practitioner, in order
to enable those who are not in hospital practice to arrive at an
independent opinion on the advisability of operation in cases of
internal lesion. In each chapter there are remarks on etiology,
pathological anatomy, clinical course, diagnosis, and differential
diagnosis, to give a general grasp of the condition under con-
sideration, and a small selection from the literature is also
added at the end of each chapter.
Being written by a physician, it is the more valuable from
the surgical point of view ; for though the writer is clearly in
sympathy with surgical methods under the circumstances defined
in the various chapters, he is nevertheless guided by a clear
judgment in recommending operation only in such conditions as
have failed to respond to medical treatment, or are clearly
unsuitable for it. The statements are concise, and the end in
view is clearly and definitely stated. We consider it a most
useful book for those in general practice who are often in doubt
as to the necessity of calling in a surgeon.
A word of praise and thanks must also be accorded to the
translator, who has so ably put into English a work which it is
highly desirable should be possessed by many who have not a
sufficient knowledge of German to read the original.
Syphilology and Venereal Disease. By C. F. Marshall, M.D.,
M.Sc, F.R.C.S. Pp. X., 509. London : Bailliere, Tindall
and Cox. 1906.
Dr. Marshall's book on syphilis is one of the most valuable
monographs that has appeared of recent years. Inspired
avowedly by the discovery of the spirochata pallida by Schaudinn
and Hoffmann in 1905, and accepting under reserve their claim
for this as the specific organism of the disease, yet so complete
is the study of syphilis in all its bearings, that wer§ the part
played by the spirochaeta proved to be something less than
at present appears likely, still Marshall's work must remain a
very valuable landmark in the field of scientific literature.
The inclusion of a complete bibliography of classical and
modern authorities stamps the book as indispensable to the
scientific investigator, while the concise and exhaustive
description of syphilis from every standpoint is set out with
such impartial judgment and wealth of detail that no prac-
titioner can afford to leave the book unread.
The subject is one that intrudes itself into every malady ;
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REVIEWS OF BCMDKS. 7I
and the effects of syphilis, its relationships, whether clinical,
psychological or sociological, in the individual or the species
are of such overwhelming moment, that so helpful a contribution
to our knowledge deserves from the critic nothing but com-
mendation.
Although the modern developments of science are fully dealt
with, the style in which they are expounded does not require
any very extraordinary pathological knowledge to be appreciated
by the reader : even one who is not in close touch with modern
laboratory methods will find himself informed, not puzzled, by
Dr. Marshall's chapters in this province.
The expermieutal work upon inoculation both in man and
monkeys is adequately described, and throws fresh light on the
infectivity of the disease, not only as regards the length of time
during which the acquired form may remain communicable, but
also as to the transmission of the inherited taint.
Marshall summarises the evidence in favour of the spiro-
chaeta pallida as the specific organism of syphilis thus : —
** I. It has been found almost constantly in the primary and
secondary lesions whether ulcerated or not.
** 2. It has also been found in the blood.
** 3. The same parasite has been found in widely-separated
countries.
*' 4. It has been found in the blood and viscera of the
syphilitic foetus.
" 5. It has been found by MetchnikofF and Roux in the
syphilitic lesions of monkeys inoculated both with human virus
and virus from other syphilitic monkeys.
** 6. It has not been found in man or monkeys apart from
syphilitic lesions."
The only one of Koch's postulates not complied with so far
is that the spirochaeta palHda has not yet been cultivated out of
the body. But the other evidence certainly seems incontrover-
tible that this is actually the specific cause of syphilis.
Unfortunately, although this conclusion may be accepted,
all efforts hitherto made to discover a method of preventing the
infection by immunisation or treatment have been in vain.
Even hereditary syphilis has proved no protection against
the acquisition of the disease in later life by the ordinary means
of infection.
The clinical manifestations and treatment are described with a
fulness to which we can only refer with admiration, in the hope
that a closer study of the recent improvements in treatment
may lead to their wider adoption and the ultimate removal
of the reproach under which the medical profession at present
(perhaps justly) lies, that in England syphilis is frequently
untreated and always inadequately.
The so-called parasyphilitic lesions — that is, diseases which
owe their origin to, but do not depend upon any pathological
change characteristic of syphilis, occupy a very important place
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72 REVIEWS OF BOOKS.
in the book on account of the valuable researches of Mott^
Ferrier, and others.
Hereditary syphilis and the proved possibility of transmission
to the third generation form perhaps, together with the advances
in pathology, the most interesting reading that Dr. Marshall
affords. The summary of facts observed in connection with the
inheritance of the disease is well worth quoting : —
** I. That the degenerative effects of syphilis are frequently
transmitted to the third generation, and possibly further, only
to die out with eventual sterility.
" 2. That, although difficult to prove, the transmission of
virulent hereditary syphilis to the next generation is possible,
and depends chiefly on two factors, time and treatment, . . . The
reason why such cases are not more common lies in the fact
that comparatively few subjects . marry while suffering from
hereditary syphilis in an active state.
** 3. That re-infection of a heredo-syphilitic genitor increases
the virulence of the disease and its fatal effects on the off-
spring.
** 4. That the two chief obstacles to actual proof of trans-
mission to the third generation are the possible re-infection
of the second generation and the possible intervention of
another syphilitic genitor. . . . For although a child is obviously
the offspring of its mother, paternal parentage is seldom
capable of scientific proof.
** 5. That the hereditary transmission of syphilis is one of
the chief factors in physical, mental and moral degeneration."
Hereditary syphilis is insisted upon as essentially contagious^
and to belittle this fact is a dangerous doctrine.
Syphilis is described as the hereditary disease par excellence y
its hereditary effects are more inevitable, more multiple, more
diverse and more disastrous in their results on the progeny and
the race than is the case in any other disease. It has, in fact, a
more harmful influence on the species than on the individual.
Dr. Marshall acknowledges his indebtedness to the teaching of
Fournier and his disciples; we in turn must with no less
gratitude confess to the debt which we owe to the English
exponent of their doctrines.
An Introduction to the Study of Colour Phenomena. By
Joseph W. Lovibond. Pp. 48. London : E. and F. Spon»
1905. — This small volume is apparently an extension of the
author's previous work on The Measurement of Light and Colour
Sensations, To the former material has been added a new
colour theory and a more elaborate system of colour nomencla-
ture. With the description of the apparatus designed for
measuring and recording colour sensation in quantitative terms
the interest which the writer commands is exhausted. By the
combination of single sensation colours (red, yellow and blue)
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•REVIEWS OF BOOKS. 73;
in thin glass plates, the tint of which is arbitrarily regarded as
a standard unit, varying depths of a particular colour and
differing shades may be imitated. As an instance we may
quote, two blue plus two red develop two units of violet ; that
is to say, white light transmitted through two thicknesses of
the unit blue glass and the unit red produces two units of
violet colour for purposes of merely empirical comparison ;.
this is interesting, and may be useful. No scientific basis for
his standard is suggested by Mr. Lovibond. As a practical
method it is attractive in its simplicity. The author's analy-
tical colour charts form an excellent means of recording in a
simple form the results of investigations with his " tintometer,"
and the application of these charts to the haemoglobinometer
earned for him a medal at the St. Louis Exposition of 1904.
When, however, the new colour theory is expounded we are
at a loss to see any reason for substituting a clumsy ** six-ray "
theory for the accepted " three-ray," and the writer does not
bring forward any arguments that make good his claim to the
discovery of a simpler or more satisfactory explanation of
colour phenomena. Nor do numerous highly-coloured, solid,,
geometrical figures make up for a total absence of all references
to rates of vibration and wave-lengths in the production of
varying colour sensations.
Studies in Blood Pressure: Physiological and Clinical. By
George Oliver, M.D. Pp. 151. London: H. K. Lewis. 1906. —
These two lectures, on the physiological and clinical aspects-
of blood- pressure measurement, are likely to be of much service
at a time when clinical haemomanometric methods are engaging
so much attention. This little book may be regarded as a
text-book by one who has been the pioneer on the subject of
haemomanometry, and whose clinical observations are most
trustworthy.
Manual of Medicine. By T. K. Monro, M.D. Second Edition.
Pp. xxii., 1022. London : Bailliere, Tindall & Cox. 1906. —
The second edition of this manual has been subjected to a^
thorough revision throughout, and a good deal of new matter
added, bringing the volume thoroughly up to date. Additional
illustrations have also been introduced. Although the work is-
longer than its predecessor, it is not unduly voluminous, and
we have failed to find any omissions of importance.
The Treatment of Diseases of the Digestive System. By
Robert Saundby, M.D. Pp. viii., 133. London: Charles
Griffin & Co., Ltd. 1906. — The most essential part of this
booklet is the introduction, an essay of forty-one pages on the
personal experience and views of a physician of large and
mature experience on a subject on which many volumes have
been and may still be written. The subsequent chapters OU'
diseases of the oesophagus, stomach, intestine and rectum, are-
such as might be culled from any text- book. A short essay on.
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74 REVIEWS OF BOOKS.
symptomatic diseases, and a long list of formulae of the ordinary
type complete the volume, which is not likely to enhance the
reputation of its already distinguished author.
Minor Maladies and their Treatment By Leonard Williams,
M.D. Pp. vii., 383. London: Bailliere, Tindall & Cox. 1906. —
This volume of 383 pages is a reprint from various sources of
lectures given at the Medical Graduates* College and Polyclinic. '
They must have served a very useful purpose, and are quite
worthy of reproduction in book form, inasmuch as much of the
contents can only be learned by prolonged experience, and is
not to be found in the text-books. The subjects are of every-
day interest and utility, ranging from the common catarrh up
to insanity, and many well-tried formulae are scattered through
the text. These are at the present time of increasing use,
inasmuch as few students learn the elements of prescribing,
and are too prone to adopt the unscientific combinations of the
manufacturing druggist, for whose benefit they are commonly
made rather than for the patient.
Uric Acid : Chemistry, Physiology and Pathology. By
Francis H. McCrudden. New York: Hoeber. 1906. — To
an inquiry as to the time of publication of his masterpiece, an
author humorously replied, **The head is on the perineum.'*
Such a phrase could never have been applied to this book.
True, it exhibits the traces of tedious labour, but there is not
a spark of life within its pages, there is nothing which stimulates
the mind or widens the imagination. It is a machine-made
book pure and simple. To borrow a phrase from the greener
isle, ** It was killed at conception.*' For the preface, with
•engaging frankness, states that the publication is made because
there is no complete and reliable account of the metabolism
of uric acid to be found in one place. Completeness, reliability
— life is short — are to compensate for vivacity, purpose, interest.
But such a programme is too extensive for even machine-
made books. Were one to be hypercritical, several errors in
chronology and omissions of work could be pointed out. It is
not necessary to do this, for with a book of this kind it is
impossible to approach perfection. Do not, however, take our
diatribe too seriously. Provided that it is necessary for anyone
to refer to the uric acid literature, then this book will save
much searching. In the States it even might assist spelling,
and that is saying much for an American book. But as the
practitioner does not care to search for literature since he
receives the Uric Acid Monthly, without cost or intermission,
and prefers to confine his spelling errors to his prescriptions,
the book then hardly appeals to him. To whom then shall
it be recommended? The physiologist, the pathologist, the
librarian, the book lover, the collector for posterity ? All these
— poor souls in more senses than one — will rejoice over this
triple essence of uric acid research and conjecture. Possession
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REVIEWS OF BOOKS. 75
will mean satisfaction — and, after all, what better does life
provide ? In this way the author may not have laboured in
vain.
On Eetro-peritoneal Hernia. By B. G. A. Moynihan, M.S.,
F.R.C.S. Second Edition. Revised and in part rewritten by
the Author and J. F. Dobson, M.S., F.R.C.S. Pp. vi., 195.
London : Bailliere, Tindall & Cox. 1906. — Since the first edition
of this work was published in 1899 a good deal of anatomical
work has been done in this subject, which has been duly incor-
porated in the present edition. It is fully illustrated, and there
is a complete bibliography of the different varieties of hernia
met with in this region. The book is certainly one of the best
accounts which we have in English on this serious affection.
The Extra Pharmacopoeia of Martindale and Westcott*
Revised by W. Harrison Martindale and W. Wynn West-
cott, M.B. Twelfth Edition. Pp. xxx., 1045. London: H. K.
Lewis. 1906. — Nearly 250 pages of new matter have been
added, and every care has been taken to make the work as
complete as possible. The authors urge rightly that it is
time that the practice which has grown up of burdening the
prescriber with metric equivalents to grains, drachms, and
ounces should be dropped m favour of metric terms only, which
involve far less mental calculation, and hence involve very much
less likelihood of error. They also urge that it would be of
general advantage if the English term minim were abandoned :
a drop might be considered as ^^ of a cubic centimetre, or
about ^ of a minim.
The Care of Children. By Robert J. Blackham, Capt.
R.A.M.C. Revised and enlarged edition. Pp. xi., 84. London:
Scientific Press, Ltd. 1906. — Truly the times have changed
from those when Kingsley could describe the army doctor as
one who thought a baby's inside much the same as that of a
Scotch guardsman. This excellent little book is written with
a view of helping to educate mothers and nurses in the simple
but essential principles of infant hygiene, by one who has been
impressed with the extremely disastrous results which are
occurring all over this country owing to the well-nigh universal
-gnorance of the populace concerning this subject. Captain
Blackham, who writes from the Military Families* Hospital,
Devonport, has evidently a ver)' practical knowledge of his
subject. He does not preach any new doctrines, but merely
sets down in clear and convenient form the accepted teaching
on infant feeding, clothing and p:eneral hygiene. The book
seems sound in every respect, and carefully prepared to meet
a very real want. We trust it may have a wide circulation
among those for whose use it has been written, and may help
to diminish the terrible infant mortality rate about which so
much is talked, though comparatively little is done to
diminish it.
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leoitorial IRotcs.
The annual meeting of this Society, held
' University College on January nth, under the presidency of
Colston Society. Sir William Selby Church, Bart., K.C.B.,
gave another opportunity for setting forth
the claims of the city for the establishment of a Bristol Univer-
sity. The occasion was a notable one, inasmuch as the Tord
Ma}'or of London (Sir William P. Treloar) was entertained as
a guest, and, further, it was the first occasion on which the
Master of the Society of Merchant Venturers had been present.
The Lord Mayor of Bristol and the Sheriff were present, also the
Vice-Chancellor of the University of Oxford, the Bishop of
Hereford, the Right Hon. Henry Hobhouse, and Sir WiUiam R..
Anson, Bart., M.P., and many distinguished citizens. The
President spoke of Edward Colston's association with St,
Bartholomew's Hospital, to which he had been a generous
benefactor, and then gave some details of the early history of
the Bristol Medical School, and of the distinguished men who
had been associated with it, and he trusted that the spirit of
Edward Colston might still operate in our midst in furtherance
of the establishment of a University for the West of England.
Mr. Henry Hobhouse spoke of the value and need of local
Universities, free from the trammels of compulsory Greek, to
concentrate their attention on the scientific and modern training,
but, he hoped, on the classical side, always ready to seek and
obtain aid and inspiration from their older sisters. He spoke of
the distinguished career of Sir William Anson, and said it was
the fashion in these days to decry University representation.
He thought it was a sufficient answer to point to the fact that
during the last ten years the Universities had sent to the House
of Commons five such men as Lecky, Lubbock, Michael Foster^
J ebb, and Anson.
Sir WilUam R. Anson, M.P., dealt with the question of the value
of University Colleges under the present educational conditions.
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EDITORIAL NOTES. ^^
The Vice-Chancellor of the University of Oxford (T. Herbert
Warren) admitted that he was a convert to the idea of local
-and civic Universities. At first he thought it was a pity and a
<langer to multiply Universities, but he had come to see that
that weis by no means the case, and that they must bring Uni-
versities home to the doors of the people in the large gatherings
•of population in the great cities. He advocated a University in
Bristol for two reasons — ^because he thought Bristol was the
light place for it, and that it would do good to Bristol. They
■ought to have a University of their own in Bristol, because
Bristol was a most admirably-situated place. With its surround-
ings, the historic associations, the poetry, so to speak, mingling
with the prose of commercial prosperity, it was a place filled
vdth opportunities for the education and elevation of the mind,
apart from its geographical position. He thought that Bristol
might fairly claim to be the next University College to take the
rank of a Universit3^
Principal Lloyd Morgan said they looked forward to the time
when Bristol would not lightly let distinguished men leave
her. They had lost good men in the past, but he hoped they
would learn more and more to secure the services of men who
came to work with them. At present the College was placed
in a difficult position, and he had often been told in America
that the position in Bristol was almost impossible. They were
preparing students for*examinations in which they had no voice,
and over which they had no control. The aim and object of
-education was to bring the individual into vital touch with his
•environment — into practical touch with his environment. Allu-
ding to the work of the future Bristol University, the speaker
pointed out that Bristol was in the midst of agricultural districts.
In developing the subject of agriculture, they proposed to have
as a beginning one or two professors who were strong both on
the scientific and the practical side, and who would be ready to
place their knowledge at the disposal of all those interested in
the question in the West of England. They would have a strong
advisory board, and had been promised the assistance of
distinguished experts.
Digitized by VjOOQIC
yS EDITORIAL NOTES.
Professor G. H. Leonard, speakings
The February 4th, on *' The University IdeaU
University Ideal, a chapter from Mediaeval History/' re-
marked that, in reference to the prospects
of a University for Bristol, one of the greatest things that
University would have to do would be to train the imagination
of man. Imagination, however, must have something whereon
to build, and it was his object to tell, as simply as he could, what
a University was, what the Universities of England and Europe
had been. The scholar wanted the master, and he found at the
University, not only the master, but other students, and the
mind was thus sharpened by contact with other minds. In
Bristol the University College had always given a cordial welcome
to foreigners, the Frenchmen, Germans, and Dutch, and those
who hailed from more distant parts and made their home amongst
them for the time. He hoped these foreigners would learn
something from us, and he wanted them to realise that much
was to be learned from them. Many in Bristol believed the
University of Bristol, with a colour and character of its own,
would attract many foreigners to our city, who would come here,
it might be, to study comrnercial geography, agriculture, litera-
ture, or some special school of medicine they would make their
own.
>ic * « * *
At the annual distribution of prizes to
Prof. Sadler the students of the Merchant Venturers
on a University Technical College, on December 21st,
for Bristol. 1906, Professor Michael E. Sadler made
a powerful appeal on behalf of a Uni-
versity for Bristol. In the course of his address he remarked
that the characteristics of all the new Universities in England
were these. Each had one centre for its work. The federal system,
by which a University was, so to speak, like a three-legged stool,
was, so far as our country was concerned, practically given up.
They got more life, more vigour, more municipal pride, more local
character if they had a University representing one great city.
It was, secondly, characteristic of all those Universities that
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EDITORIAL NOTES. 79'
the examinations should follow the teaching, instead of the
teaching being subservient to the examinations, and there
was the wise provision by which there was an externa] and
independent examiner. The third characteristic was that they
regarded provision for research as absolutely indispensable for
the educational vitality of the institution. No teacher could
teach properly unless he himself was going on learning. The
fourth characteristic was that the Universities were open, without
let or hindrance, to men and women of all ranks and all sorts,
and, so far as their resources permitted, they would teach any-
thing which the locality thought it was desirable to have taught,
and not only in the daytime. One of the great problems we had
to face in this country was to enable men who had entered work
to take their degree by a systematic series of evening courses.
It was a difficult work, because they could not work a competent
teacher by day and night ; but it was a problem we had to face
and to solve. In this connection he could not but recall to their
recollection that in that city, unless he was mistaken, were the
first beginnings of that adult school movement, more than one
hundred years ago, which, for his own part, he regarded, thfough
its spirit of brotherliness and common service, as perhaps the
most remarkable of all the educational movements of our time
in this country. But large resources were indispensable to a
modern University, and the one thing which. made him hesitate
in laying this suggestion before them was that he could not
disguise from them the fact that year by year the efficiency and
maintenance of a great University became more and more
expensive. The country would not gain by the establishment
of Universities, weak because ill endowed and ill equipped with
the right kind of teachers, or with the necessary laboratories and
libraries and other buildings which the social life of a great
University required. If they took a survey of University life,
they realised how elastic things were. They might practically
build a University according to the local need, and adjust its
organisation to the different requirements of the different
districts, but it was highly important, where possible, to unite
in one institution the component parts of their University.
Digitized by VjOOQIC
'80 EDITORIAL NOTES.
Union was good for administrative purposes ; it was good for
the interchange of thought between student and teacher ; it was
good for the discipline — a much more important part of modern
University Hfe than was generally realised ; and it was good for
future growth, because a single institution appealed more to
the imagination, to the State, to the locality, and to the good
wishes of the intending benefactor. Th^y wanted one Council,
one professional Senate, one academic head. But under these
circumstances variety was possible within wide limits. As, for
example, at Sheffield, where the Technical College, though an
integral part of the University, had its own special traditions
and its own history. A great University in Bristol would be the
crown of the educational system of the city and district. What
we had learnt in the last few years in England had been that
national education Wcis one thing from top to bottom with good
primary schools, first-rate secondary schools, and great Univer-
sities, and, through their reciprocal influence and need, indispen-
sable the one to the other. A University here, well endowed,
would furnish Bristol and its neighbourhood with a succession of
men fitted to hold the most responsible posts in the scientific
enterprise and organisation of modern industry and commerce.
And the rapid growth of Bristol encouraged the hope that its
citizens would ere long emulate the example of Manchester,
Liverpool, Birmingham, Leeds, and Sheffield, and other great
cities in building up a modern University. The intellectual
influence of a University here would make Bristol, as it used to
be in old days, the lantern of the west. The great historical part
of Bristol, and of the West Country, would be an inspiring
influence in the work of its University. As Burke — ^perhaps the
greatest name connected with Bristol— said, " Our country is an
ancient tradition into which we are born." It was our business
to blend the old with the new, and a University was oite of the
centres in which that work could be carried on. And, apart
from its intellectual resources, each great city University ought
to have halls of residence, in order that the students might enjoy
the characteristic benefit of English academic tradition, namely
the social training which one got from the give and take on
Digitized by VjOOQIC
EDITORIAL NOTES. 8l
«qual terms of collegiate life. And our aim should be to give
the rising generation of Englishmen and Englishwomen the best
possible opportunity of physical and intellectual training that
the world could offer — something which would strengthen and
•deepen character and fortify will. And we could aim at nothing
higher than that the outcome of our education should be fairness
of mind combined with capacity for decisive action.
The scientific world has sustained a great
Sir loss in the death of Sir Michael Foster,
Michael Foster. K.C.B., F.R.S., D.C.L., M.D. Lond. He
possessed a vigorous personaUty, and as
Professor of Physiology at Cambridge for twenty years has
exercised a vast influence over the science which has become so
completely transformed since the time of Bowman and Carpenter.
The scientific development of Physiology in this country has been
mainly due to Foster and his pupils, and the University of
Cambridge and the Royal Society owe much of their present
prestige to the mind and work of the late Member for the
University of London. The following personal reminiscences
have not been in print elsewhere, and are worthy of record : —
An archaeological friend writes : "I well remember a pleasant
midsummer day at Cambridge, some years ago, spent in the
company of Professor Michael Foster, on the invitation of an
intimate friend of his. He met us at the station, and devoted
the whole day to showing us the colleges ; he did not seem to
•care much for the antiquities of the place, and rather treated
the subject with subdued scorn. Pointing to the saints in the
windows, he said, ' Perhaps they will have me up there one day.'
" At that time he held strong radical views, which he rather
impressed on me by saying, with reference to the old saying,
* Whatever is, is right ; ' but I say, ' Whatever is, is wrong.' I
was much struck with his genial humour, giving way now and
again to peals of laughter.
** After dinner he sent his man to row us on the Cam. He
told me that he had been with the Professor for many years,
7
ToL. XXV. No. 95.
Digitized by VjOOQIC
82 EDITORIAL NOTES.
his duty being to anaesthetise the animals for vivisection. He
never knew one single case of an animal being allowed to suffer
pain, for the animal was always unconscious before the operation
began, and was always despatched before it could recover
consciousness."
The spread of the mysterious and fatal
Cerebro-spinal malady known incorrectly as " spotted
Fever, fever " is causing considerable alarm.
Professor Osier states that in New York
there have been nearly four thousand cases within the last two-
years, and that as many as three thousand have been fatal.
The necessity for anticipating precautions of comprehensive
character is never more evident than in the case of the possible
invasion of a district by a comparatively unknown disease.
Hence we have endeavoured to give a brief outline of what is
known of the disease in an article (page 14) compiled by the
Medical Officer of Health for Bristol in conjunction with the
Pathologist to the Bristol Royal Infirmary, describing some of
the latest known of the salient points in regard to the causation,,
prophylaxis, and treatment of this disease, and it is hoped that
by united action on the part of the profession and of the public
authorities, any introduction of cerebro-spinal fever in epidemic
form may be promptly averted or checked.
Meantime the name of the disease is of some importance
The term cerebro-spinal meningitis is too comprehensive,,
inasmuch as it includes all forms of meningitis. The term
spotted fever was formerly used as synonymous with typhus,,
and should still be retained for this disease, in which petechial
spots are always present, rather than for a disease in which they
are commonly absent. It seems more than likely that many of
the earlier epidemics of so-called spotted fever may have been
really typhus. Although we rarely see typhus fever now, its-
name, spotted fever, should not be attached to a malady of
which the pathology and bacteriology are totally different.
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NOTES ON PREPARATIONS FOR THE SICK. 83
Within the last few months a considerable
Pathogenic amount of work has been done upon the
Organisms. metabolic reactions of staphylo-, strepto-
and diplococci. The results attained
appear to have a practical bearing upon the diagnosis and treat-
ment of infectious conditions, and we hope to present a resum6
of the researches and their applications in our next issue.
IRotcs on ipreparatione for tbc SicFi*
Colalin ; Colalin Laxative.^T. Morson & Son, London, —
These two preparations are in tablet form, the dose of colalin
being half a grain, one tablet to be taken three or four times a
day. It is considered to be pure cholalic acid, an amorphous
powder, insoluble in the stomach, but soluble in the upper
intestines, from whence it is absorbed, as no traces of cholalin
are found in the fseces. It is believed to stimulate the liver
and cause an increased flow of bile.
The laxative tablet contains a combination of cholalin with
the anthraquinone principle of csiscara. These bile preparations
are said to be of genuine therapeutic value in cases of functional
affections of the liver ; the promoters of them state that they
may be absolutely relied upon to stimulate the flow of bile, and
more especially to convert an abnormal viscous bile into a normal
and viscid one. In one case the effect of this tablet on the bowels
was found to be insignificant.
Liquid Somatose. — Bayer Co. Limited, 19 St. Dunstan's Hill,
London, E.G. — ^This preparation is introduced for the convenience
of those who find the powdered somatose troublesome to dissolve.
The nutrient properties are mainly due to the presence of
proteoses and alkali albumen ; the unsweetened solution gives
no precipitate on boiling, but a dense precipitate on addition of
an acid, which completely disappears on heating, and reappears
on cooling. The biuret reaction gives a pink colour, with dilute
solutions. There are two varieties of Liquid Somatose, a sweet-
ened and unsweetened, the latter being available for diabetics,
and the former recommended for children. Both are quite
palatable, and the former may be added to soup or beef-tea
without spoiling the flavour of these dishes.
Formamint Tablets. — ^A. Wulfing & Co , 83 Upper Thames
Street, London. — ^Formamint is a chemical combination of formic
Digitized by VjOOQIC
84 NOTES ON PREPARATIONS FOR THE SICK.
aldehyde with lactose. The tablets dissolve readily in the
mouth ; they produce an abundant flow of saliva, which, contain-
ing formic aldehyde, has an effective antiseptic action in the
throat. They are considered to be the best substitute for gargles,
and as they are to be dissolved slowly in the mouth, their action
is likely to be much more prolonged. They are quite palatable
and non-irritating, so that they may be readily taken by children,
and should be effective in all cases of sore throat when a non-
irritating antiseptic is desirable.
Tabloids : Guaiacol Camphorate, gr. v. ; Calcium Lactate,
gr. V. ; Pectoral Pastilles. — Burroughs, Wellcome & Oo.,
London. — ^The Guaiacol Camphorate Tabloid should be a con-
venient form of administration of two useful drugs in cases of
phthisis. The guaiacol has deservedly established a reputation,
and in its combination with another drug also of established
reputation, camphoric acid, its value should be greatly
enhanced.
Calcium Lactate is employed to increase blood coagulabiHty,
which has been shown to be deficient in cases of urticaria and
other affections. Its administration has proved successful in
the treatment of urticaria, chilblains, certain forms of albu-
minuria, headache, and serum rashes. It is also employed in
aneurism and in various forms of hemorrhage, including the
hemorrhagic form of small -pox ; as a preventive and curative
in haemophilia, in uterine hemorrhages, and preliminary to
surgical procedure. ** Tabloid " Calcium Lactate presents a
convenient and satisfactory means of administering a calcium
salt. Calcium Lactate is now preferred to the chloride, which
has sometimes been found to produce disturbance of the alimen-
tary canal. This tabloid is non-irritating, readily soluble and
easily absorbed. One or more may be taken twice or thrice
daily for two to three days.
" Tabloid " Pectoral Pastilles contain ammoniated liquorice,
squill, tolu, senega, ipecacuanha, wild cherry, etc. They afford
a palatable and convenient means of exhibiting aromatic, expec-
torant, demulcent and sedative principles. Slowly dissolved in
the mouth, these pastilles exert a prolonged and uniform effect
on the respiratory tract. They relieve cough, check excessive
secretion, and soothe the irritated mucous membrane. They
should be valuable in colds, hoarseness, and bronchial affections.
Phenofax. — Burroughs, Wellcome & Co., London. — ^This
antiseptic surgical dressing contains 7 per cent, of pure phenol in
a bland basis. It may be applied on lint, or may be used as an
ointment in parasitic skin diseases. It is also suitable for applica-
tion to affected mucous surfaces, more especially ulceration of the
cervix uteri.
Digitized by VjOOQIC
LIBRARY. 85
Soloid — Eosin-azur. — Burroughs, Wellcome & Co., London.
— ^We have examined this ** Soloid." Each soloid contains 0.015
gm. of Giemsa's stain, and is dissolved in 5 c.c. of pure methyl
alcohol. When the staining directions are properly followed, the
results are thoroughly satisfactory. These ** soloid " stains are
most convenient for use, and are reliable as regards their staining
properties.
Ubc Xibrars of tbe
Bristol /lDeMco*CbirurQical Societi?*
The following donations have been received since the puhlicaticn
of the List in December :
February 28th, 1907.
J. Paul Bush, C.M.G, (i) . . . . . . . . 5 volumes.
Medical Officer of the London County Council (2) . . i volume.
Middlesex Hospital (3) . . . . . . . . i
The Pathological Society of London (4) . . . . 2 volumes.
The Council of the Royal College of Physicians of
London (5) . . . . . . . . . . i volume.
Scholastic Trading Company (6) . . . . . . i ,,
James Swain, M.D. (7) . . . . . . . . i
The Director of the U.S. Census Report (per W. Roger
Williams) (8) . . . . . . . . . . 2 volumes.
Unbound periodicals have been received from Mr. Paul Bush
and Dr. James Swain.
SIXTY-THIRD LIST OF BOOKS.
The titles of books mentioned in previous lists are not repeated.
The figures in brackets refer to the figures after the names of the donors,
and show by whom the volumes were presented. The books to which no
such figures are attached have either been bought from the Library Fund
or received through the Journal.
Berard, A. Poncet et L. Traite clinique de V Actinomycosis humaine 1898
Buxton, D. W. Anessthetics 4th Ed. 1907
Catalogue of Accessions to the Library of the Royal College of Physicians
of'London (5) 1906
Catalogue of the Pathological Museum of the University of Manchester 1906
Catheart, C. W. The Essential Similarity of Tumours 1907
Clubbe, C. P. B. Intussusception 1907
Encyclopedia and Dictionary of Medicine and Surgery, Vol. III. . . 1907
Haab, 0. . . Atlas of the External Diseases of the Eye (Ed. by
G. E. de Schweinitz) 2nd Ed. 1906
„ . . Atlas and Epitome of Operative Opthalmology (Ed.
by G. E. de Schweinitz) 1905
Hartmann, H. Les Anastomoses intestinales (i) 1906
Hewitt, F. W. AneBsthetics and their Administration . . 3rd Ed. 1907
Hurdon, H. A. Kelly and E. The Vermiform Appendix and its Diseases 1905
Keetley, C. B. The Prevention of Cancer 1907
Digitized by VjOOQIC
86 LIBRARY.
Kelly and E. Hurdon, H. A. The Vermiform A ppendix and its Diseases 1905
Klein, E The Bacteriology and Etiology of Oriental Plagi^e . . 1906
McCaw, J. . . Aids to the Treatment of Diseases of Children. 3rd Ed. 1907
Moynihan, B. 6. A. Abdominal Operations 2nd Ed. 1906
Needlandicorum, Opuscula Selecta. De Arte medica, Fasc. I. . . 1907
Owen, E. . . Cancer : its Treatment by Modern Methods . . . . 1907
Palmer, Margaret D. Lessons on Massage 3rd Ed. 1907
Poncet et L. Berard, A. Trait6 clinique de l' Actinomycosis humaine 1898
Richardson, H. The Thyroid and Parathyroid Glands 1905
Ritchie, R. P. The Early Days of the Royal Colledge of Phisitians,
Edinburgh (i) 1899
Savage, W. G. The Bacteriological Examination of Water Supplies 1906
Sutton, J. B. .. Tumours, Innocent and Malignant ,, .. 4th Ed. 1906
Swanzy and L. Werner, H. R. Diseases of the Eye . . . . 9th Ed. 1907
Taves, A. W. . . The Etiology and Diagnosis of Epidemic Cerebro-
spinal Meningitis 1906
Wallace, F. C. Surgery of the Rectum 1907
Weber, Sir H. and F. P. Climatotherapy and Balneotherapy . . 1907
Werner, H. R. Swanzy and L. Diseases of the Eye . . 9th Ed. 1907
Whiteford, C. H. Glimpses of American Surgery in 1906 1906
Whiting, A. . . Aids to Medical Diagnosis 1907
TRANSACTIONS, REPORTS, JOURNALS, &c.
American Association of Obstetricians and Gynecologists, Transac-
tions of the Vol. XVIII. 1906
American Dermatological Association, Transactions of the . . . . 1905
American Journal of Obstetrics, The Vol. LIV. 1906
American Ophthalmological Society, Transactions of the
Vol. XI., Part I 1906
Archives of the Middlesex Hospital (3) Vol. IX. 1906
Association of American Physicians, Transactions of the Vol; XXI. 1906
Boston Medical and Surgical Journal, The Vol. CLV. 1906
Bristol Directory, Wright's 1907
British Almanac, The 1907
British Medical Journal, The Vol. II. for 1906
Clinical Journal, The Vol. XXVIII. 1906
Edinburgh Medical Journal, The Vol. XX. 1906
Epidemiological Society of London, Transactions of the Vol. XXV. 1906
Gazette des Hopitaux 1906
Gazette hebdomadaire des Sciences m6dicales de Bordeaux
Tom. XXVII. 1906
Glasgow Medical Journal, The Vol. LXVI. 1906
Hazell's Annual 1907
Hospitals —
Boston City Hospital, Medical and Surgical Reports of the . . (7) 1905
Guy's Hospital Reports Vol. LX. 1906
St. Bartholomew's Hospital Reports Vol. XLII. 1907
Journal of Tropical Medicine, The Vol. IX. 1909
Lancet, The Vol. II. for 1906
Digitized by VjOOQIC
MEETINGS OF SOCIETIES. 87
London County Council, Annual Report of the Medical Officer of the,
for 1905 (2)
Medical Chronicle, The 4th Series, Vol. XI.
Medical Directory, The
Medical Press and Circular, The [Vol. CXXXIIL]
Medical Review, The Vol. IX.
Montreal Medical Journal, The Vol. XXXV.
Nord medical, Le
Nordiskt Medicinskt Arkiv
Odontological Society of Great Britain, Transactions of the
Vol. XXXVIII.
Ophthalmological Transactions Vol. XXVI.
Otological Society of the United Kingdom, Transactions of the
Vol. VII.
Pathological Society of London, Transactions of the
(4) Vols. LVI., LVII. 1905—
Practitioner, The [Vol. LXXVIL]
Progres medical, Le Tom. XXII.
Progressive Medicine Vol. IV.
Publishers' Circular, The (6) Vol. LXXXV.
Revue hebdomadaire de Laryngologie Tom. XXVI.
Sanitary Record, The Vol.XXXVIIL
Scottish Medical and Surgical Journal, The . . Vol. XIX.
Society for the Study of Disease in Children, Reports of the
Vol. VI. 1905—
United States, Twelfth Census of the, 1900 . . . . (8) Yols, III., IV.
West London Medical Journal Vol. XI.
"Whitaker's Almanack
Year-Book of Scientific and Learned Societies, The
Zentralblatt ftir Chirurgie
Zentralblatt fur Gynakologie
906
906
907
906
906
906
906
90s
906
906
906
906
906
906
906
906
906
906
906
906
902
906
907
906
906
906
MEETINGS OF SOCIETIES.
JBristol /iDeMco^Cbiruroical Societs*
December 12th, 1906.
Mr. James Taylor, President, in the Chair.
Dr. E. C. Williams showed a Case of Rheumatoid Arthritis
in a girl aged twelve.
Dr. B. M. H. Rogers showed (i) A Child of two years of
age weighing only seven pounds, and (2) A case of Optic
Neuritis of sudden onset.
Dr. Rogers also read notes of a case of Narcolepsy. — ^Dr.
A. Rendle Short compared petit mat and its persistence to
the disease under consideration, — Dr. Stack said the condition
suggested that induced by mesmerism, and asked if the pupil
Digitized by VjOOQIC
88 MEETINGS OF SOCIETIES.
had been contracted in the sleep or not. In the mesmeric state*
he thought the pupil was not contracted, though it was in
somnambulism, — ^Dr. Rogers replied that the sleep looked like
ordinary sleep.
Mr. E. W. Hey Groves read a paper on A New Method of
Fixation in Excision of the Knee-joint. The apparatus devised
and recommended by the speaker consisted of iron rods, which
were passed from side to side through the femur and through the
tibia. The projecting ends of these were braced together on
each side by two more rods having screw ends. The apparatus
fixed the bones immovably together. It was advisable to make
a mortise and tenon junction of the femur and tibia. He had
used the apparatus successfully in four cases. — Mr. J. Lacy Firth
said the difficulty in fixing the bones in this operation Was greater
in proportion to the youthfulness of the patient and the softness
of the bones, and asked if the speaker's patients had been children
or adolescents. He thought that the bones might rotate on the
rods passed through them, though he had not actually tested
the apparatus, especially if the bones were soft, as was often the
case. He had found that steel pins, psissed from the tibia into-
the femoral condyles, crossing one another as they passed from
the outer tuberosity of the tibia to the inner condyle, and from
the inner tuberosity to the outer condyle, were satisfactory,
unless the bones were very soft. — Mr. Groves rephed that his-
apparatus could be screwed up, so that the femur and tibia were
tightly braced together and could not move upon each other..
None of the patients had been very young, and three of them
twenty years of age or more.
Dr. E. C. Williams read the concluding notes on a case of
Spleno-megalic Biliary Cirrhosis (vide p. 43). The patient had
been shown to the Society a year previously. — Dr. Fortescue-
Brickdale showed the organs obtained at the post-mortem exam-
ination of the case, and microscopical sections. — Dr. Michell
Clarke, from an examination of the specimens, thought the case
had not been one of biliary cirrhosis. The specimens looked
more like those in ordinary cirrhosis of the liver. It was difficult
to deny that the specimens were like those in Banti's disease.
Intestinal poisons might cause cirrhosis as well cis alcohol. —
Dr. Walker Hall said the microscopical specimens suggested
Banti's disease. Some fissures on the right lobe of the liver
suggested that the cirrhosis was syphilitic. The sections showed
capsular and interlobular cirrhosis. — Dr. Carey Coombs thought
the changes in the liver were the result of irritation, transmitted
to the organ by the bile ducts, systemic arteries, or portal vein.
There appeared to be no evidence that the bile ducts or the
artery had been the channels of conduction. The cirrhosis was-
very like the alcoholic form, and the poison had probably come
from the intestinal tract through the portal vein. — Dr. Williams^
Digitized by VjOOQIC
MEETINGS OF SOCIETIES. 89'
in reply, said there might be no jaundice in the juvenile type of
the disease. By Banti's disease was meant the terminal stage
of splenic anaemia of adult type, in which affection the spleen
was the first organ to be affected. The child was too young for
that, the disease having begun at four years of age. The splenic
anaemia of infants is a totally different disease. No results had
been observed from anti-syphilitic treatment in the case.
Salicylate of soda had done most good.
Dr. Kenneth Wills read a paper on Eighty Cases of Lupus
Vulgaris treated by Radio-therapy.
January gth, 1907.
Mr. James Taylor, President, in the Chair.
Dr. Charles read notes on a case of Multiple Myelomata and
Albumosuria. — Mr. Roger Williams pointed out that myelo-
matosis occurs without albumosuria. Albumosuria was not the
disease, it was a secondary phenomenon. Such cases as that
described were formerly called multiple sarcomata of bone. It
seemed clear that the disease was not sarcomatous, and likely
that it belonged to the leucaemic class of diseases, and, like those,
was due to an infective agency. The disease had affinities with
Paget's osteitis deformans. — Dr. Markham Skerritt pointed out
that not much was known about albumosuria and its causation.
It was sometimes met with in pneumonia. He had met with
an example of albumosuria in a medical man which persisted
for twelve months. Later serum-albumin was found in the
urine, with signs of chronic interstitial nephritis. Ultimately
the patient died of acute pneumonia.
Dr. MiCHELL Clarke read a paper on Some Complications
of Pneumonia. — Dr. Coombs referred to four cases of pneumo-
coccic peritonitis of which he was cognisant. Three of
them had been apparently primary. Of these, two children
and one adult had recovered. It would be interesting to know
whether the affection was more often primary or secondary. —
Mr. Carwardine mentioned a case of diplococcic peritonitis he
had met with. The child developed pneumonia after the
peritonitis was established. — Dr. E. C. Williams mentioned two
cases of pneumonia with complications he had treated. In one
delusional insanity had arisen. The second was complicated
with hiccough, which lasted four or five days, and nearly killed
the patient. Obstinate hiccough used to be a more common
complication than it was now. In his case morphia had been
ineffectual as a remedy. — ^Dr. Markham Skerritt mentioned a
case of pneumonia in which thrombosis of the pulmonary artery
carried off the patient.
Drs. Walker Hall and Carey Coombs demonstrated various,
macroscopical and microscopical pathological specimens.
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90 OBITUARY.
February i^th, 1907.
Mr. James Taylor, President, in the Chair.
An address was given by P. H. Pye-Smith, Esq., M.D.,
F.R.C.P., F.R.S., on Prognosis (vide p. i).
©bituar^ IRoticcs*
HERBERT W. KENDALL, F.R.C.S.
By the death, on December 23rd last, of Mr. H. W. Kendall, of
Redland, the profession has lost a colleague who, both as a student
and practitioner, was characterised by steadfast integrity of
character and aim. He passed away at the early age of 39, after
an illness of three weeks' duration, the end coming suddenly from
pulmonary thrombosis dependent on lung trouble, following an
attack of appendicitis, and at a time when he was showing signs
•of apparent recovery ; his sudden death was a termination some-
what unexpected by his friends, and by the several medical and
surgical colleagues who anxiously attended him.
As a general practitioner, he spared no time or pains for rich
and poor alike. It was his very nature to be thorough in his work
and kind in his ways, denying himself at the call of duty, and
gaining the esteem of both patients and colleagues.
For several years past he was Honorary Surgeon to the
Bristol Royal Hospital for Sick Children and Women ; he was
an able operator, and was much respected by the staff, com-
mittee, and nurses. His death will be a great loss to that
institution, which he served so faithfully and well. He was also
Medical Officer to the Maternity Home, and to the Surgical Aid
Society ; and, though holding several public appointments, he
performed the duties of all thoroughly and creditably.
Mr. Kendall started practice in Bristol in 1895, after holding
the posts of House Surgeon to the Great Northern Hospital, and
of House Surgeon and Obstetric Officer to the Middlesex Hospital,
where he studied in London. He leaves numerous professional
and lay friends to mourn his loss.
ALFRED SHEEN, M.D. St. Andrews, M.R.C.S. England,
D.P.H. Cantab.
Born at Leicester in 1839, and educated at Hurstpierpoint,
Alfred Sheen found the routine of a Civil Service appointment at
Madras uncongenial, and in 1856 he entered the Madras Medical
College, where he carried ofi many prizes, and found time to be
ajleading member of the Madrsis Cathedral choir. Yet unqualified,
lie returned to England in medical charge of a large ship. His
student days were completed at Guy's Hospital, where he obtained
Digitized by VjOOQIC
OBITUARY. 91
the Physical Society's prize for an essay on ** Dysentery," In
1862 he qualified. In the following year the " Guyite Club " of
1863 was founded, of which he remained a member to the time
of his death. Alfred Sheen's hfe work in Cardiff began in 1864,
when he was appointed House Surgeon to the Cardiff Infirmary,
at that time a small institution of some thirty beds. The House
Surgeon was not only in charge inside, but also had to visit sick
in the town, patients of the charity, and act as Secretary and
General Superintendent. In this, his earliest work in Cardiff,
Alfred Sheen acquitted himself weU, displaying that abundant
energy and power of work which were so characteristic of all his
after life. He it was who first organised the " Infirmary Balls,"
ever since a successful annual function. In 1866 private practice
was commenced; marriage and appointment to the Infirmary
Honorary Staff followed shortly afterwards. Active practice
was continued for forty years ; indeed, to within a month of
his death.
During his many years as Surgeon to the Cardiff Infirmary
Alfred Sheen showed the greatest zeal, thoroughness and
industry in his surgical work. He gave much time to the
institution, and in the earlier days, when actual operations were
not so numerous, much of the " case-taking " and dressing was
done by his own hands. His perfect ambidexterity was a
feature of his operating. The writer recalls best his trans-
parent pleasure at the rapid and successful completion of an
ovariotomy, and the slow, painstaking and methodical way
in which he would dissect out a mass of tuberculous glands
from the neck. Naturally at a time of change numerous inno-
vations and additions were due to him ; inter alia, he was the
first to displace " antiseptic " by '* aseptic " methods in Cardiff.
In the numerous general duties which fall to a hospital adminis-
trator Alfred Sheen was always to the fore. When the Infirmary
w^as moved to its present position in 1883, it was in the main due
to his efforts that the site was obtained from the Marquis of Bute.
He superintended every detail of its building, and, in addition,
was an indefatigable collector of money to start it free from the
burden of debt. It would not be too much to say that the Cardiff
Infirmary building as it now exists stands as a monument to
Alfred Sheen.
Space forbids reference to Alfred Sheen's many other activi-
ties — Initiator, Secretary and Treasurer of the South Wales branch,
and until recently member of the Central Council, of the British
Medical Association ; Visiting Medical Officer to the Cardiff
Workhouse Hospital, and an authority on Poor Law Medical
Work; an original member of the Cardiff Medical Society, its
first Secretary, at one time its President, and its first Honorary
Member ; Initiator, Treasurer, Chairman of Committee and
Honorary Medical Officer of the Cardiff branch of the '* Jubilee
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92 OBITUARY.
Nurses " ; a most active and useful member of the Council of
University College, Cardiff ; Treasurer and Hon. Surgeon-Colonel
of the Church Lads' Brigade ; Churchwarden of St. German's,
Cardiff, to the time of his death — these are some of the many
active and useful ways in which his life was spent. I^^l^ ^
There are certain members of the community to whom people
instinctively go in time of trouble, and Alfred Sheen was one of
these. All through his life, by correspondence or by interview,
there came to him many who needed advice and help on various
subjects, and advice and help were always willingly, carefully,
and thoroughly given. Underneath a reticent and somewhat
blunt manner was concealed an exceeding kindness of heart.
His medical pubHcations were as follows : —
BIBLIOGRAPHY OF ALFRED SHEEN.
" Strangulated Inguinal Hernia ; operation ; death ; necropsy." — Lancet^
1878, ii. 879.
'* Poisoning by Phosphorus ; post-mortem examination." — Brit. M. J.^
1879, i. 347.
** On Iodoform." — Practitioner, 1879, xxii. 321 — 324.
" Intestinal Obstruction ; puncture of the intestine ; left lumbar colotomy ;
recovery." — Brit. M. J., 1879, ii. 733.
" Provident Dispensaries." — Ibid., 1880, i. 753.
" Five Years' Surgical Work in the Cardiff Infirmary." — Lancet, 1880.^
ii. 532, 613, 688, 764, 928.
'* Colotomy in the Left Loin." — Ibid., 929.
" Can a threatened attack of Diphtheria be averted." — Ibid., 1881, ii. 11 50.
" Two cases of Aneurysm of the Femoral Artery with Ligature of the
External Iliac Artery ; recovery." — Brit. M. J., 1882, ii. 720.
" Nitrite of Amyl and Nitro-Glycerine in Uraemic Asthma." — Ibid., 1883,
i. 811.
" An Epidemic of Tetanus." — Bristol M.-Chir. J., 1883, i. 173 — 183.
" Three cases of Intestinal Obstruction." — Ibid., 1884, ii. 167 — 174 ; also*
Brit. M. J., 1884, ii. 1014.
" An Address on the Relations of the Medical Profession. " — Brit. M. J.^
1884, ii. 896 — 901.
" On Diphtheria, with cases." — Bristol M.-Chir. J., 1885, iii. 113 — 124.
" Strangulated Hernia and its Treatment." — Brit. M. J., 1887, i. 387 — 389,
" Case of Stricture of ^Esophagus ; gastrostomy ; death." — Ibid., 1889^
i. 1463-
" Two cases of Trephining." — Ibid., 1890, i. 236 — 238.
" Pleural Effusions, their Diagnosis and Treatment." — Bristol M.-Chir. /.,.
1893, xi. 14 — 29.
The Workhouse and its Medical Officer. 2nd edition. Bristol : Wright
& Co. 1890.
" Selections from my Casebooks." — Brit. M. /., 1895, i- 9 — 12.
" A case of Axial Rotation of the Testis." — Lancet, 1896, i. 990.
" On an Outbreak of Small-pox at the Workhouse, Cardiff." — Brit. M. J.,
1896. i. 835—837.
" Three Severe Operations in one Patient. (i) Abdominal Incision for
Perityphlitic Abscess ; (2) Cceliotomy ; (3) Hepatomy for Abscess in
Liver." — Practitioner, 1896, Ivi. 607—611.
" A case of Puerperal Septicaemia treated by Antistreptococcic Serum ;
death." — Brit. M. /., 1896, ii. 1774.
" Case of Traumatic Rupture of the Duodenum and Jejunum." — Ibid.r
1899, i. 470.
" Recovery from Morphine Poisoning after Subcutaneous Injection of
Atropine." — Ibid., 1905, i. 1040.
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LOCAL MEDICAL NOTES. 93
Also papers on
' Indoor Medical Relief."
'Women's Work in Populous Parishes."
' Hospital Accommodation for Infectious Diseases in Cardiff."
Xocal flDcMcal IRotcg*
University College, Bristol. — ^A distinct step has been taken
towards the University of Bristol by the complete incorporation
of the Medical School with University College. The resolution
agreeing to this was passed at a recent meeting of the Governors
of the College. The present building has been used by the
Medical Department for fourteen years, but there has so far been
only co-operation between the two bodies. The present in-
corporation will increase the status of the School and College.
The Medical School was at work more than forty years before
the College was founded, and amongst its lecturers were some of
the best men of the day. Hundreds of highly-trained men have
been sent out by the School, which for so long stood in seclusion
in the old Park — and Bristol medical men are to be found in all
parts of the world.
Long Fox Lecture. — Dr. P. Watson WiUiams has been appointed
lecturer for this year. It will be given in November, and the title
and date will be announced in a later issue of this Journal.
Examination Results. — Students of the Medical Faculty have
recently passed the following examinations : —
F.R.C.S. Eng. — Primary Examination : C. A. Joll, B.Sc. Lond.
Conjoint Board. — Medicine: P. S. Connellan, C. E. K.
Herapath. Surgery: J. W. J. Willcox, J. Ellington Jones*,
L.S A. Midwifery : P. S. Tomlinson.
L.D.S., R.C.S. Eng. — Mechanical Dentistry and Dental Metal-
lurgy : R. J Burton. Final- Examination, I, : W. H. Ireland.
//. ; F. C. NichoUs*.
* Completes Examination.
Bristol Royal Infirmary.— C. F. Walters, F.R.C.S. Eng., has
been appointed Surgical Registrar; W. W. King, M.R.C.S.,
L.R.C.P., Resident Obstetric Officer ; and A. J. Turner, M.B., B.S.
Durham, Junior House Surgeon.
Bristol General Hospital.— T. E. Coulson, M.B., Ch.B. Edin.,
has been appointed Senior House Surgeon.
The following description of the new Isolation Block at the
Bristol General Hospital, opened by the Lord Mayor and Lady
Mayoress of Bristol, in the unavoidable absence of Lady Smyth,
who had promised to perform the ceremony, on January 26th,
1907, will be of interest.
The limited area of the site necessitated a somewhat unusual
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94 LOCAL MEDICAL NOTES.
arrangement of plan. The building consists of two parts joined
by a narrow, cross- ventilated neck. The south portion is devoted
to accommodation for the patients and the northern part to that
for nurses. The building contains two floors, the upper floor
being reached by a separate staircase approached from the outside,
so that there is no internal connection between the two floors.
Each floor contains two wards of two beds each and one ward of
one bed, with duty room, two bedrooms for nurses, and the usual
baths and sanitary arrangements, stores, &c. Care has been
taken to avoid crevices, where dust or other deleterious matter
could be harboured ; all surfaces are smooth and easily cleaned.
The doors are of the Gilmour type, now generally well known ;
they have the appearance of being made out of a solid plank,
but actually they are made up of a number of pieces, and veneered
so that they present a perfectly smooth surface without ledges or
sinkings ; they are finished with white enamel. The walls are
plastered with cement and will ultimately be finished with
enamel. The floors are of EuboeoHth, a material laid in a plastic
state, afterwards hardening and receiving polish. It is jointless,
waterproof, fire-resisting, and unaffected by temperature. There
is a heating chamber in the basement, and the warming is by hot
water on the low-pressure principle, with ventilating radiators of a
type easily cleaned. The extraction is by means of an electric fan.
At the Annual Meeting of the Bristol General Hospital, held on
March nth, under the presidency of the Lord Mayor, an excellent
report for the past year was presented, which stated that excep-
tionally heavy demands had been made on the resources of the
Hospital, both financially and in the work of treating a larger
number of patients than has hitherto been recorded. The posses-
sion of the second operating theatre continued to lead to the in-
creasing number of cases requiring operations of a more or less
serious character being promptly dealt with. The isolation wing
was now completed and fully equipped, and the formal opening
recently took place. The work done at the Avonmouth Hospital
under the medical officer and sister in charge had been considerable.
The number of in-patients was 2,165, and that of the out-patients
35,264 — a record number for the institution. 482 patients were
sent to the convalescent home, with beneficial results. As regards
finance, the ordinary expenditure exceeded the income — which
had remained the same as in 1905 — by £2,626. The workpeople's
contributions amounted to £2,225, ^m amount which almost
equalled the annual subscriptions. During the coming year it is
hoped to raise £12,000, to enable two important additions to be
made, which are needed to keep the institution thoroughly up to
date. We feel sure that with the example of Bristors public spirit
quite fresh in our minds, which aided Sir George White to raise
£50,000 for the Infirmary, this sum is not too much to ask for, con-
sidering the great work that is carried on at the General Hospital.
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LOCAL MEDICAL NOTES. 95'.
Bristol Royal Hospital for Sick Children and Women.— L. N.
Morris, M.R.C.S., L.R.C.P., has been appointed Senior House
Surgeon.
Newport General Hospital.— J. B. V. Watts, M.B., B.Sc. Lond.,
has been appointed House Surgeon.
Bristol Dispensary. — ^The committee of the Bristol Dispensary-
report that the number of patients recommended for relief in 1906
has been 10,323, viz. 7,997 at Castle Green and 2,326 at Bed-
minster, this being an increase over the previous year of 282. The
number of notes sold to subscribers was 11,322. The committee
much regret to record the death of their esteemed colleague, Mr..
J. Hudson Smith, who had been a member of the committee for
22 years, and who generously remembered the institution in his will.
W. H. A. Elliott, M.B., B.S.Lond., has been elected an additional
surgeon to the institution.
The Bristol Medical Dramatic Club, which has now reached its
twenty-ninth season, recently gave performances of Home, Sweet
Home, with Variations. The performances were a great success,
and the proceeds will be handed to the Medical Clubs' Union
for the promotion of its endeavour to secure an athletic ground.
Royal United Hospital, Bath. — A public meeting was held at
the Guildhall, Bath, on January 22nd, under the presidency of
the Mayor, to consider the financial position of the Royal United
Hospital, and the best means of reducing the debt of £5,000
which exists on the institution. The Mayor will make an effort
to wipe off the debt during his year of office, and stated that he
had already received several subscriptions for this purpose.
After some discussion the meeting pledged itself to support the
Mayor in his admirable determination to place the Royal United
Hospital on a sound financial basis.
South Devon and East Cornwall Hospital, Plymouth. — ^Lionel
Shingleton Smith, M.R.C.S., L.R.C.P., has been appointed House
Surgeon to this hospital.
Devon and Cornwall Ear and Throat Hospital. — ^The twentieth
annual meeting of the subscribers to the Devon and Cornwall Ear
and Throat Hospital, Plymouth, was held on February 5th, under
the presidency of the Mayor. The medical report stated that
during 1906 there had been 987 patients treated, compared with
859 in 1905, and that 23 in-patients had been admitted against
12 in the previous year.
" Index Medicus.'' — An intimation has been issued by the
Carnegie Institution of Washington that " unless it appears that
the Index Medicus is of greater service to the medical profession,
and can help to support itself to a greater extent than in the past,
it may become advisable to discontinue its publication.'* The
Index Medicus was established in 1879, and died for want of
support in 1899. ^^ ^9^3 ^^^ Carnegie Institution made a grant
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96 LOCAL MEDICAL NOTES.
•of jf2,ooo a year to keep it alive, whilst the subscription price was
reduced from /5 to 25s. per annum. We understand that the
total number of subscribers is 532, of whom 396 are in the United
States. All those engaged in bibliographical research will re-
member how difficult and tedious searching for references became
when the Index Medicus ceased in 1899, and it is to be hoped that
many doctors — ^we will not say medical libraries, as we hope there
are none who are not subscribers — ^will acknowledge the generosity
of the Carnegie Institution by becoming subscribers. The
subscription (25s.) defrays only about one-fifth of the cost of
production.
Pathological Demonstrations. — ^On February 14th Dr. J. M. H.
Eyre, of Guys Hospital, London, gave a demonstration on
Pneumococci at the Bristol f^ye Hospital, upon the invitation
of Professor Walker Hall. Dr. E5n:e pointed out the differences
in the several types of pneumococci, and deprecated the depen-
dence upon morphological characters alone for routine diagnosis.
He insisted that numerous cultural tests should be carried out
before any diplococcus was designated as the pneumococcus.
He also remarked upon the manner in which the tissues resisted
the pneumococcal organisms. In some cases a cellular, in others
a fibrinous exudation, marked the response. Dr. E5n:e considers
that pneumonia is a distinct septicaemic condition, the cocci
being present in the blood stream at an early period of the
-disease.
On February i8th Professor Walker HaU gave a lantern
' demonstration on epidemic cerebro-spinal meningitis and malaria
and blood diseases at the Royal Infirmary. He showed some
of the new serum, detailed its mode of preparation, and explained
the manner of its application.
We understand that Professor Symmers, of Belfast, is shortly
expected to take one of these demonstrations. The subject will
be " Bilharziosis." Professor Symmers was able to obtain a
large number of specimens during his tenure of office in Cairo.
Bilharziosis is now becoming so common in this district, that we
feel sure everyone will be glad of an opportunity of discussing
the condition.
We are enabled to state that the coming summer " Friday "
demonstrations will assume rather a different character from
those of the past winter session. Dr. Walker Hall proposes to
devote the entire term to the diseases of the stomach and intes-
tines. The bacteriology, parasitology, and chemistry of the
tract will be considered in detail, and the ulcerations and obstruc-
tions will be dealt with fully. A feature of the course will be
the condition of the gastric and intestinal mucosae and contents
in diseases of the circulatory, respiratory, renal, and nervous
: systems. Practitioners will be admitted on presentation of their
cards.
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CATALOGUCO
E. H. B.
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^be Bristol
ill>ebico*Cbimroical Journal
" Scire est nescire, nisi id me
Scire alius scireet, ' '
JUNE, 1907.
©bituar^ IRotice^
EDWARD MARKHAM SKERRITT, M.D., F.R.C.P.
Thou whom none knoweth, yet they lie
Who say Thou art not, speak with me !
I am because Thou bidst me be,
And when Thou bidst me, I must die. . . .
Oh, rend the Heaven ! Break up the height,
The depth, between Thy works and Thee !
Tear off the veil, that Earth may see
The fount of good, the judge of right ! * — Bourdillon.
It is only human to desire to record some memorial of a man we
have lost, especially when he has been associated with us in many
years of similar work, and when we so well know that his life was
a model from which we may ourselves draw many useful lessons.
In the twenty-five years of the life of this Journal we have had
many occasions to give an " In memoriam " record of the lives of
those who have gone before. Our readers will remember Augustin
Prichard, Edward Long Fox, William Johnstone Fyffe, Joseph
Griffiths Swayne, Henry Marshall, Aust Lawrence, and the first
^ Monthly Review, March, 1907.
8
Vol. XXV. No. 96. ^ ,
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98 OBITUARY NOTICE.
editor of this Journal, James Greig Smith, whose life, all too
short, was terminated somewhat abruptly in the midst of active
work by an attack of pneumonia. And now we have to lament
the death of Edward Markham Skerritt, also prematurely cut off
by pneumonia at perhaps the most useful period of his career.
We cherish the memory of our *' mighty dead," but their mes-
sage to us is that it is the business of man to keep things going ;
no one of us is indispensable, but, nevertheless, the best of us are
much missed at the time of departure. He who has so lived as
to ** leave the world a little better than he found it," must of
necessity leave a gap when his chair becomes vacant.
That such a gap followed the death of Dr. Skerritt was shown
by the striking demonstration at the funeral, which took place on
Thursday, May 2nd, 1907, when the presence at St. Paul's Church
of a very large number of mourners, including a large proportion
of his own profession — by whom he was so much esteemed — gave
the most pronounced testimony to the widespread feeling of
regret that his life's work had ended. He was buried at Redland
Green amidst every manifestation of sadness and regret, expressed
not only by his own immediate friends, professional colleagues
and patients, but by representatives of the various public bodies
with which his work had been associated.
Edward Markham Skerritt was born at Chelsea on December
30th, 1848, and he died on Monday, April 29th, 1907, at the
comparatively early age of 59. His education commenced at
Mill Hill School, but afterwards he was sent to Amersham Hall
School, where he found as school-fellows many associates who
have risen to considerable distinction in various walks of life.
His early education appears to have been of a robust and vigorous
if not of an ascetic type, and he ever after lived a most active,
strenuous career, never sparing himself or taking rest and quiet.
On leaving school he matriculated at the University of London
(1866), and graduated as B.A. Lond. in 1868. In the following
year he passed the Preliminary Scientific M.B. Examination, and
then entered as a medical student at University College, London,
at a time when this school was in a very vigorous state, and
attracted a large proportion of the ablest students in London,
Digitized by VjOOQIC
E. MARKHAM SKERRITT. 99
many of whom have come to the front and are occupying leading
positions in London and the provinces. With such competitors
Skerritt easily held his own ; he won many prizes and class
distinctions, and when he passed the examinations for the M.B.,
B.S. he obtained the University gold medals for Physiology,
Medicine, and Obstetric Medicine. In 1874 he obtained the degree
of M.D. Lond. As a student he was noted for his unflagging
industry, and a methodical habit which enabled him to acquire
knowledge easily and to learn accurately. Although reserved,
he was much liked by his fellow students, who admired his ability,
and were attracted by his simple straightforwardness. As a
mark of the success of his student's course he was elected a
Fellow of his College, and he obtained the Atkinson-Morley
surgical scholarship, which was the highest surgical distinction
open to him. As Sir John Erichsen's house surgeon, and Sir
William Jenner's house physician, he had the fullest opportunity
of gaining the soundest medical and surgical skill, so that by his
own natural ability, and by the best possible training, it was felt
that Skerritt had laid an excellent foundation for a very distin-
guished career. It was in 1875 that a vacancy for ph^^sician —
caused by the death of Dr. Samuel Martyn — at the Bristol
General Hospital gave the opportunity which the electors wisely
accepted when they appointed him to serve in an institution
which for thirty-two years since has gained so much from his
painstaking and skilful work as physician. He became M.R.C.P.
in 1876, was elected a Fellow in 1885, and afterwards a
member of the Council of the Royal College of Physicians of
London.
As a clinical teacher he will long be missed. His instruction
was good, and he was earnest in imparting it. Many generations
of old Bristol students must have a grateful recollection of the
benefits they have themselves obtained by his example as well
as by precept. As Joint Lecturer and later Professor of
Medicine (this course having been always divided between
a member of the staff of the Infirmary and one from the
Hospital) he was methodical and clear ; he devoted especial
attention to diseases of the heart and lungs, and these lectures,
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100 OBITUARY NOTICE.
with a course on general febrile maladies, usually occupied the
whole of the time available.
For many years he acted as Secretary, and afterwards becanae
the first Dean of the Medical Faculty in the University College.
A colleague writes, *' These offices were no sinecure, and gave him
an enormous amount of work, as the negotiations for incorpora-
tion extended over some years. . . . Dr. Skerritt was ex officio a
member of the Council of the College, and in all matters medical
was the authority ; but his knowledge of business, his sound
judgment and shrewd common sense, made him a valuable
member of the Council in all that related to the welfare of the
College." The engineering Chairman of the Council once re-
marked to the writer that Skerritt appeared to be *' a very level-
headed person ; *' and so he was, for he had a wholesome detesta-
tion of fads of all descriptions. It was felt that he was not only
a skilled physician, but a wise counsellor, a man of sterling
uprightness, and of unimpeachable sincerity, essentially a man
to be trusted.
He held in turn all the offices which the local profession had
to offer. He never declined anything which appeared to be his
duty, or in which he could do good service. As Secretary for many
years of the Bath and Bristol Branch, as President of the Branch,
as a member of the central Council of the Association, as Treasurer
of the Association in 1902, and Vice-President in 1904, he was a
mainstay of the British Medical Association, and during the last
few years, when intricate details under the new constitution have
been much discussed, Skerritt's knowledge and clear judgment
have been invaluable. Others have written on these points in
the Journal of the Association (May nth, p. 1159), ^^^ with regrets
that '* his place in our Council Chamber is empty, and with
sorrowful hearts we say farewell to one who has left us before his
time.*'
Skerritt was one of the very early members of the Bristol
Medico-Chirurgical Society, and was rarely absent from its
monthly meeting. He was President in 1892-3, and then gave
a very characteristic presidential address on *' The Teachings of
Failure.*' Many other papers and addresses have been published
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E. MARKHAM SKERRITT. lOI
from time to time in this Journal, and it will be generally ad-
mitted that Skeriitt never wrote for the sake of writing, and that
whatever he wrote is worth reading. He was not a voluminous
writer, but he always had an object in his writing, and expressed
himself clearly and concisely. His Bradshaw Lecture, given before
the Royal College of Physicians in 1897, is an excellent outline
of things which had passed through his mind for many years,
and in which he held very definite views. He had no great
ambition to be known as an author ; his time was actively
employed in other ways. He was no advocate of a gospel of
inactivity, but his powers were commonly expended in other
fields.
The Queen Victoria Jubilee Convalescent Home has, from its
commencement, derived the advantage of Dr. Skerritt's presence
on its Board of Governors, and his work there is shown by the
resolution adopted by them at a meeting on May 17th, as follows :
" The Governors of the Convalescent Home desire to place on
record their sense of the great loss the City and many of its most
useful institutions has incurred in the removal of one whose
remarkable abilities were only equalled by his kindness, of heart
and his readiness to serve others. They record especially their
appreciation of the interest he took in the founding of this Home,
the value of his aid in arranging all its organisation, and the
(Constant service he rendered in its management.'*
Another institution which owes much to his services is the
Winsley Sanatorium for the poorer consumptives of the three
neighbouring counties. He was a member of the original execu-
tive committee, and he took a leading part in the initiation and
furtherance of a method of treatment which his long experience
of chest diseases had shown to be most desirable. It was a
satisfaction to him to feel that this Institution is now in good
working order, and is becoming more and more increasingly
useful.
With one exception he was the oldest member of the Medical
Reading Society, and he was present at the centenary meeting,
when eighteen past and present members met at dinner on
April 3rd. He was then in good health and spirits, looking
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102 OBITUARY NOTICE.
strong and wiry as usual, with a good expectation of a long
continued career of useful activity. The monthly meetings of
this Society have conduced much to the furtherance of good
fellowship, and Skerritt's presence has doubtless tended towards
the diminution of such professional jealousy and rivalry as at
times exists amongst many professional communities. Skerritt
was elected a member of this little Society in 1876, so that he
had assisted in over one-third of its centenarian life.
With regard to the social characteristics of Skerritt, the
following personal appreciation is written by one of his most
intimate friends, Dr. Barclay J. Baron : —
" My friendship with Edward Markham Skerritt began in
1883, when, as a new-comer to CHfton and a near neighbour, I
called on him. He was courteous and kind, as was his wont,
but, more important, he was distinctly encouraging as to my
prospects of practice in Bristol. This faculty of encouraging
younger members of the profession in times of difficulty was a
trait in his character of peculiar value to many of us. He invited
me to go round the wards of the General Hospital with him, and
of this invitation I availed myself, during the next year, on many
occasions. I profited greatly by the clear, logical way in which
he arrived at a diagnosis. I was struck by his faculty for dedu-
cing feasible theories as to the causation of disease from ascer-
tainable facts, and in particular by the simplicity of his
therapeutic measures. Markham Skerritt was no more attracted
by newly introduced, well advertised or fashionable drugs than
he was by the change of fashions in millinery, and I 'feel certain
that in this respect his influence as a physician was of a decidedly
beneficial character. At this time he prescribed alcohol for
patients in smaller quantities than most men, and as his experi-
ence increased he prescribed it less and less, until, in his last days
it certainly occupied an unimportant place in his medical
armamentarium. His great reliance was on rest and warmth,
on vis medicatrix naturcB rather than on drugs.
*' In 1884 my humble dwelling was visited one evening by
. Skerritt and Aust Lawrence, and the greeting of the former was
' Le roi est mort : vive le roi ! ' This meant that the late Dr.
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E. MARKHAM SKERRITT. IO3
Burder had presented his resignation of the physiciancy of the
Bristol General Hospital to his colleagues, and Skerritt asked me
if I would become a candidate for the vacant post. Largely
owing to his support I was appointed without contest, and thus
became his Hospital colleague. I had by this time formed a very
high opinion of my new friend, but I had never seen him in counsel
with other senior members of the profession until the first staff
meeting took place. I was gi'eatly interested in finding that my
•estimate of him was that held by all his colleagues, and if ever a
difference of opinion arose Markham vSkerritt almost invariably
induced the staff to adopt the views which he himself held. In
debate he was certainly very strong, because he never placed
himself in a position of antagonism to others without having first
satisfied himself that he was right, and with rare ability he never
under-estimated the strength of his opponents' attack, and so
was fully prepared to meet and overwhelm it.
" Others have spoken to his Hospital and University College
•career, and to his sterling value to practitioners in consultation.
As a consultant, as indeed in other relations of life, Skerritt
listened rather than talked. He was distinctly reserved, and,
indeed, many patients would have liked him to unbend and say
more. In point of fact, he was essentially a home-loving man.
He donned a dress-coat unwillingly, and was seen but little at
clubs and dinners ; but he received his guests in his own house,
at all times, with the refined hospitality of a large heart. Those
of us who knew him intimately in Clifton found that he very
frequently relaxed the stiffness of his manner, and was full of
humour and good fellowship. ^But to see Markham Skerritt
full of the love of life, really humorous and genial, one must
have done as I did, gone down and stayed with him on Dartmoor
or Exmoor. When I first visited him at Throwleigh, near Chag-
ford, I was met at the farmhouse gate by him with no hat, with
certainly no waistcoat, I believe without a necktie. He had then
not quite developed his intense devotion to open air living, but
he had at least joined the ' hatless brigade.' It was a charming
picture of family happiness which greeted me as he, his wife, his
daughter and I wandered over those grand old moors. He was
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104 OBITUARY NOTICE.
intensely observant of the ever-changing beauties of flower and
insect life, sunshine and cloud, and deeply impressed by the
wonderful solitude of the Devon Tors. For his was indeed a
very simple, natural mind, and whilst he pretended to no profound
knowledge of Botany or Entomology, he lived his days of leisure
on the countryside with a spirit very responsive to its open
secret.
" On another occasion I visited him at AviU, near Dunster,
whither he was in the habit of taking horses and hunting with
the Devon and Somerset Staghounds. By this time he had
become a great devotee of the open air, and it was his delight
for us all to have breakfast in front of the farmhouse door at a
table where a robin, which he had induced to recognise us as
friends, came regularly to feed from our plates. On one occasion
Aust Lawrence was also a guest, and on the cold days — ^which
sometimes set in at the end of August — it was a constant source
of entertainment to watch him (for he hated too much cold air)
taking every opportunity of our host's temporary absence from:
the room to shut the casement windows, and to see Skerritt on
his return, finding that the curtains were not properly blowing
about, open the windows again with distinct rumblings of wrath
at the stupidity of servant girls who did not appreciate their
privilege of living in God's air.
" Whatever Skerritt did he did with all his might, and hunting
was no exception to the rule. I have known him on horseback
from early morning till evening under a blazing sun, with no more
refreshment than a feW raisins and a little chocolate, and his
' pistol ' full of cold tea. He never, with that modesty we all
know was so deeply ingrained in his nature, talked much of
wonderful runs at which he had been present ; but once a well-
known sportsman, comparing him with another hunting doctor,
said : * — 's heart is as big as a threepenny bit, but Skerritt's
is as big as your hat.'
** Skerritt was genuinely fond of physical and mental hard
work. I spent many an hour watching him dip clinkers in a
bucket of cement to build them together into a large fernery at
Thornton House. He worked harder than any mason could have
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E. MARKHAM SKERRITT. IO5
been induced to do, without coat, waistcoat or collar, and with
his sleeves rolled up, and was bubbling over with fun when he
was nearly caught by patients in this unclothed condition. He
stayed with me in the country at my cottage, and begged to be
put to work in the garden. He and I spent many an hour at the
back-breaking labour of strawberry planting, and more than once,
when I had a mind to ease off for a time, he compelled me by
precept and example not to be lazy. He took a deep scientific
interest in watching my gardener's attempts to overcome an
invasion of * spot ' in tomato plants, and was as delighted as a
schoolboy when he, his wife, my wife and I, cut into a peach
weighing 17 oz. which my gardener had grown.
'* He had a great love of altering the residences which he
purchased, and employed no architect to draw his plans. For
months he was busy designing and seeing executed the beautiful
oak room which served as a waiting-room at Thornton House
and at Edgecumbe House, and the beloved fittings of which
followed him to the house in which he died, and were there
re-erected. In this last place of residence he gratified to the full
his architectural talent. Moreover, he undertook personally the
improvements in his lovely garden, and discussed with me, as if
the matter were one of extreme importance, the selection of apple
and pear trees. In the last weeks of his life — ^in fact, up to the
very last day he was able — he was engaged in heavy rock work
in the quarry attached to his house, which even involved blasting.
This work my dear old friend leaves, like few things to which he
put his hand, unfinished.
" Many years ago he and I went to Berlin together to see for
ourselves what we could of the value of Koch's Tuberculin. I
am bound to confess that I had intended to make this something
of a picnic among m}^ old German friends, but I found I was
vastly mistaken. Skerritt went to work, and work he did from
morning to night, and compelled me to do the same ; and in
the week we spent there we worked as hard as I have ever done
in my life. This was Markham Skerritt, and his powers of
endurance were such that it was extremely difficult to keep pace
with him. On our return we wrote a joint paper on Koch's
Digitized by VjOOQIC
k/) obituary notice.
treatment of Tuberculosis, which appeared in the Bristol Medico-
Chirurgical Journal (Vol. VIII.). This we started to compose at
8 p.m., and Skerritt left me in a most dilapidated condition at five
the next morning, having written — ^with a short interlude for
supper — right through the night. So stubborn was his iron consti-
tution, that he was able to go home, have his bath, and set about
his daily round of work. When in Berlin we stayed in the house of
my honoured old friend Sanitatsrat Dr. Patschkowski, and during
our stay our hostess celebrated her birthday. I shall never
forget seeing Skerritt with a huge bouquet — which we had
purchased for the occasion — in his hand, ushered into a room
where a dozen German ladies were in the midst of a ' Kaffee
Klatsch,* nor at the supper which afterwards took place, hearing
him — who knew no German, whilst some of the guests knew little
English — endeavour to converse and make a little speech in Latin.
I have had extremely kind messages of condolence with his widow
from the friends he then made, showing that he has not been
forgotten.
" As husband, father and friend, Markham Skerritt was a
rare soul. He ever gave more than he wished to receive ; he
ever gave of his very best. His judgment was sound and unerring,
and his desire to help all those who came to him was boundless.
Busy as he was, he could always find time to help others. His
opinion was expressed with complete independence to friend,
doctor and patient alike, and while such independence may be
said to come more easily from men in easy circumstances, this,
in my opinion, has no bearing whatever on what was a sterling
quality of Markham Skerritt's mind. It was a characteristic
proper to him by inheritance, and fostered by environment.
" The shock of the death of his only child — coming to a man
of his reserved but deep and tender nature — was one from which
he never completely recovered. Long after her death his wife
and he dined quietly at my house, and more than once in the
course of light conversation his eyes filled with tears, and I knew
that he was standing by a graveside. Once speaking to him about
it, and apologising, as I did, for reopening a wound, his reply was :
You have not done that, my friend, because it is always open.'
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E. MARKHAM SKERRITT. IO7
" On Monday, 29th April, large numbers of us felt that one
of the finest types of Christian gentlemen whom it has ever been
our happy lot to know left us and joined the great majority."
Geo. W. Russell, speaking of the Ideal Character, remarks :
** The man who owns it may be very homely, very insignificant ;
as the world judges, very uninteresting. But the character itself
bears the sign-manual of Heaven, writ large in purity and courage,
and gentleness and unselfishness ; and the man, by a secret power
which he has never realised, leavens the world in which his lot
is cast.'* And further he quotes from Dr. Liddon : " It is by
the work of grace in lives such as this that both the church and
society are braced and sanctified ; it is from such lives that a
truer, loftier, more disinterested, sterner, yet withal, most
assuredly not less affectionate spirit than that of common men
radiates into and elevates an entire generation.*' ^
BIBLIOGRAPHY OF EDWARD MARKHAM SKERRITT.
*' On the treatment of Empyema by Lister's Antiseptic Method." — Brit.
M, J., 1876, ii. 109.
^' On the treatment of Acute Rheumatism." — Ibid., 1877, ^i- I04» i33-
*' Spontaneous Rupture of the Spleen." — Ibid., 1878, i. 641.
^' Complete Obstruction of Intestine by Croupous Inflammation." — Ibid.,
1878. ii. 367.
*' Acute Tuberculosis." — Tr. Bristol M.-Chir. Soc, 1878, i. jy — 80.
■" Croton-chloral in Neuralgia." — Ibid., 10 — 15.
** A case of Abdominal Aneurism, becoming diffused after distal compres-
sion." — Ibid., 102 — 108.
** Subcutaneous Emphysema and Infiltration, with pus following aspiration
for pyo-pneumothorax." — Ibid., 112 — 115.
•"' Intestinal Perforation from Ulceration, with Abdominal Tumour of
obscure origin." — Ibid., 87.
" Facial Paralysis from Cerebral Tumour." — Ibid., no — 112.
" Remarks in discussion on High Temperature." — Ibid., 135 — 137.
■** A case of Complete Obstruction of the Intestine by Fibrinous Exudation,
with Latency of Acute Symptoms." — Tr. Clin. Soc. Lond., 1879,
xii. 97 — 102.
** On the Simulation of Ascites in cases of Intestinal Obstruction." — Ibid.,
224 — 228.
** Clinical Evidence against the Contagiousness of Phthisis." — Bristol
M.-Chir. /., 1883, i. 48 — 70.
"" On the Conduction of Physical Signs in Diseases of the Lungs." —
Proc. M. Soc. Lond., 1885, viii. 55 ; also Brit. M. J., 1884, ii. ICX35.
*' Acute Febrile Glycosuria." — Brit. M. J,, 1885, ii. 1052.
■** Actinomycosis Hominis." — Internat. J. M. Sc, 1887, xciii. 75 — 88.
"" Diseases of the Lungs and Organs of Respiration." — Y ear-Book of Treat-
ment, 1889 — 96.
^ Social Silhouettes, Smith, Elder & Co., 1906.
Digitized by VjOOQIC
I08 DR. J. MICHELL CLARKE
" Koch's Treatment of Tuberculosis." — Bristol M.-Chir, J., 1890, viii,
(Supplement).
*' Oxy8:en Gas in Acute Respiratory Affections." — Brit. M. J., 1892, i. 269.
** Clinical Lecture on Interlobular Emphysema of the Lungs." — Ibid., loio.
Presidential Address to the Bristol Medico-Chirurgical Society on " The
Teachings of Failure." — Bristol M.-Chir. J., 1892, x. 229 — 249.
""Caffeine in Diseases of the Respiratory Organs." — Practitioner, 1895, liv.
318—322.
Presidential Address to the Bath and Bristol Branch of the British Medical
Association on " Some Current Topics in the British Medical Associa-
tion." — Brit. M. J., 1896, ii. 119 — 121.
The Bradshaw Lecture on " Prognosis in Heart Disease." — Ibid., 1897, ii.
1327 — 1332; a.\so Lancet, 1897. ii- 1163 — 1167.
" Case of Protracted Sleep extending over fifty days." — Brit. M. J., 1898,
ii- 957-
" Hospital Management in Bristol." — Practitioner, 1901, Ixvi. 671 — 672.
" Some Points in the Diagnosis and Prognosis of Heart Disease." — Poly-
clinic (Lond.), 1902, vi. 61 — 67.
" On Cardiac Pain." — Proc. M. Soc, Lond., 1902, xxv. 181 — 196.
CASES ILLUSTRATING THE MORE UNUSUAL
COMPLICATIONS OF PNEUMONIA.
BY
J. MiCHELL Clarke, M.A., M.D.Cantab., F.R.C.P.,
Professor of Medicine, University College, "Bristol ;
Physician to the Bristol General Hospital.
The following cases illustrate some of the rarer complications
met with in pneumonia. The occurrence of such complications
forms one of the strongest arguments in support of the modern
conception of pneumonia as a general infection. These instances
occurred in a consecutive series of 126 cases of pneumonia. They
comprise peritonitis (2) ; thrombosis of vessels (3), in one of
which there was also general pneumococcic infection ; endo*
carditis (2) ; nephritis (i) ; arthritis (i). In the same series
there were also three cases of delayed or imperfect resolution
of the consolidated lung, and three cases of empyema, neither
of which I have thought it worth while to report. With regard
to cases of imperfect or absent resolution, it may be remarked,
however, that if an example of this condition comes under
observation for the first time at some considerable interval after
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ON COMPLICATIONS OF PNEUMONIA. IO9
the original illness, valuable aid is given in diagnosis by the
commoa circumstance that the consolidated area corresponds
•exactly to the superficial delimitation of one lobe of a lung on
the surface of the chest.
There is also a point of importance in empyemata following
pneumonia, that is, that at an early stage firm adhesions may
unite the visceral and parietal pleurae along the septa between
the lobes of the lung, and thus on the right side there may be
a collection of pus over the lower lobe entirely shut off by ad-
hesions along the interlobar septum from another smaller col-
lection over the middle lobe. This happened in one of the above
-cases of empyema, in which after the pus had been evacuated
from an empyema over the right lower lobe it wsls found necessary
to do a further operation for a small collection of pus exactly
•corresponding to the superficial extent of the middle lobe, and
•completely shut off from the first one.
Pneumococcic Peritonitis. — Peritonitis is a rare complication
of pneumonia, although, as is well known, severe pain in the
upper part of the abdomen accompanied by great diminution
in the respiratory movements in the same situation is common,
and occasionally leads to. errors in diagnosis. Though peritonitis
is said to occur in pneumonia by direct extension through the
diaphragm, it would seem more generally the result of a general
pneumococcic infection, as appears likely in the following in-
stances, which occurred in two sisters.
Winifred B., aet. 9, admitted February 7th. The patient
^hen aet. 3 had several attacks of convulsions, but with this
exception, although never robust, she had had no serious illness.
On January 15th she went to school apparently in good health,
but returned midday with a pain in her stomach, and vomited.
The next day she was delirious, but this delirium soon passed off.
During the next fortnight she suffered from severe paroxysmal
pain in the abdomen, relieved by rubbing it. For the first week
she was repeatedly sick, and the abdomen swelled and became
hard. She had a troublesome, painful cough, the tongue was
thickly furred, and an eruption of labial herpes appeared.
On February ist the skin gave way over the umbilicus, and
about two quarts of thin, greenish-yellow fluid was discharged,
with great relief to the pain. Since that day there had been a
slight discharge from the umbilicus. The bowels were moved
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no DR. J. MICHELL CLARKE
regularly throughout. On admission the child was thin and
emaciated, with the remains of labial herpes about the mouth.
On admission, February 7th, the chest was small and badly
formed. There was some dulness over the base of the right lung,
with coarse rales in the axillary region, and over the left base
bronchial breathing and some small crepitations. The heart was
normal. The abdomen was distended, its walls rigid, and there was
a feeling of resistance about the abdomen generally. It moved on
respiration. There was a sinus, discharging pus, at the umbilicus.
There was dulness over the front of the abdomen, but the flanks
were resonant and there was no evidence of free fluid. The
temperature was hectic, varying between normal in the morning
and 101° at night.
The general appearance of the child and the physical signs in
the abdomen suggested abdominal tuberculosis ; examination of
the pus from the sinus, however, showed no tubercle bacilli, but
the pneumococcus was obtained in pure culture.
The blood gave erythrocytes 2,650,000, white corpuscles 15,00a
to c.mm. A small incision was made just below the umbilicus,
and a large cavity, shut off from the rest of the peritoneum, was-
discovered between the omentum and the anterior abdominal
wall, from which about two pints of pus were evacuated. After
the operation the temperature fell to normal, the sinus graducdly
closed up, and she left the hospital quite well five weeks later.
On March 2nd Bessie B., aet. 4, the sister of the above
patient, was admitted, with the history that on January 24th,
three days after her sister was taken ill, she developed a bad cold,
with fits of shivering and several attacks of vomiting. During
the next two weeks she was very ill with high fever, a bad cough,
and pains in the chest and abdomen. The pains in the abdomen
were paroxysmal, at times very severe, and were relieved by
poultices. There was diarrhoea at first, but the bowels were after-
wards moved regularly. The vomiting ceased after the first week.
The abdomen became swollen, distended, and hard, and as the
child did not get better, she was brought to the hospital.
On admission the child was pale and emaciated. There were
a few scattered rales at the bases of the lungs, otherwise there
were no abnormal physical signs in the chest. The pulse was
120; respiration 30; temperature 99.5°. The abdomen was
much distended, measuring 22J inches at umbilicus. It was dull
all over, except in the epigastric region. There was a distinct
fluid thrill. The skin around the umbilicus was red and dusky.
The abdomen moved very little with respiration.
The day after admission Mr. Morton made a small incision
between the umbihcus and xiphoid cartilage, and evacuated a
large quantity of greenish yellow, fairly thick pus. On examina-
tion the organisms obtained gave the cultural characteristics of
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ON COMPLICATIONS OF PNEUMONIA. Ill
the pneumococcus. The after history of the case was uneventful,
the discharge rapidly diminished, and the patient left the hospital
quite well twenty-five days later.
The interesting point is the occurrence of the same complica-
tion, and that an uncommon one, in two sisters, and also, in the
first case, the close resemblance clinically to abdominal tuber-
culosis, at once cleared up by the discovery ot the pneumococcus
in the pus.
Cases of Thrombosis of Vessels. — ^Thrombosis is a rare com-
phcation of pneumonia. In 27 out of 32 cases collected by
Steiner the time of its appearance was during convalescence.
According to Osier, it nearly always occurs in the femoral veins,
and is still more uncommon in arteries than in veins.
Thrombosis of Left Superficial Femoral Vein. The patient
was a strong, healthy collier, of temperate habits. He had a
severe chill on December 24th, and on the 25th a rigor with pain
in the left side of the chest, and was admitted into hospital on
26th with the signs of lobar pneumonia at the left base. The
course of the pneumonia was uneventful, and terminated by
crisis on December 31st. The heart's action was well sustained
throughout ; there were no murmurs ; the pulse was good, vary-
ing from 80 — 96. A leucocyte count on the fifth day gave 45,000
to c.mm. The urine was normal. On the thirteenth day, when
convalescence was apparently proceeding normally, the tempera-
ture, which had been normal for five days, rose to 99.5°, and he
complained of pain in the left groin and calf, and the left thigh
and leg swelled with great rapidity. The next day a hard, tender,
band-Hke swelling could be felt along the course of the left super-
ficial femoral vein, and a swollen vein on the calf leading up to
this. There was no further constitutional disturbance, and no
sign of any heart affection. Under the usual treatment pain and
swelling gradually subsided, and by the end of January all evi-
dence of the thrombosis had disappeared. He left the hospital
well on February 3rd.
The most notable feature of the case is the rapid onset, and
the equally rapid clearing up of the lesion, in marked contrast
with the tedious course of most cases of thrombosis of the femoral
vein. The cause was obscure ; there was no general infection,
and no affection of the heart, whilst the well-marked leucocytosis
in a moderately severe attack of pneumonia showed that the
patient's resistance was good.
Thrombosis of Cerebral Vessels. J. H., aet. 25, had always
enjoyed good health, but was said to have had a slight discharge
Digitized by VjOOQIC
112 DR. J. MICHELL CLARKE
from the right ear before present attack. It was doubtful, however,
whether this discharge was more than a Httle wax. He had felt
ill for a week before, being obliged to give up work on October
29th. He was first seen by Mr. E. H. C. Pauli on October 31st,
who found that his temperature was 102°, and that there was
pneumonia of the lower lobe of the right lung. The crisis occurred
on November ist, and he was apparently doing well, when on
November 3rd he had two slight rigors, an attack of general
epileptiform convulsions, and his temperature, previously normal,
rose to 101°. He vomited several times, and complained of
headache. The temperature remained about 102°; there was
no paralysis of any muscles, no recurrence of rigors, nor fresh
symptoms, but on November 4th he became drowsy, and this
gradually deepened into coma.
On November 6th, when I saw him, he was in a condition of
moderately deep coma ; he did not speak, but opened his eyes
when shouted at. The pulse was 120 ; the respiration 32,
irregular and often sighing. There was deficient resonance over
the base of the right lung, and redux crepitant rales were heard
here. The cardiac apex beat and area of dulness were normal,
the pulmonary second sound accentuated and the first sound at
the apex indistinct. Abdominal organs normal. The pupils
acted to light, and were of moderate size, the right larger than
the left. There was no localised paralysis ; he could move his
limbs ; the arms were flaccid, the legs a little rigid at the knees.
There was no rigidity of the neck muscles. The knee-jerks were
present, not inpreased ; the plantar reflexes were extensor in
character ; there was no ankle-clonus.
He could not swallow on this day ; and there had been in-
continence of urine and faeces for two days. The right ear con-
tained wax, so that the drum could not be seen. The outline of
the optic discs appeared a little blurred, but they were not
hyperaemic, and there was no definite optic neuritis. On making
a lumbar puncture, about i J ounces of perfectly clear, limpid fluid
without any deposit were withdrawn.
In view of the difficulty of diagnosis in this case, the result of
the lumbar puncture was especially important, as it enabled one
to exclude meningitis, and probably intra-cranial abscess, a
possible complication in view of the uncertain history of discharge
from the ear. Thrombosis of cerebral veins was thought to be
the most probable diagnosis.
The patient died the same evening. An examination of the
brain was made at his home under considerable difficulties.
Unfortunately, the result of this examination was negative, as
the exact cause of the cerebral symptoms was not made out, but
it was valuable as proving the absence of meningitis and intra-
cranial abscess. Thrombosis of cerebral vessels is not always
easily recognised, especially under the conditions in which the
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ON COMPLICATIONS OF PNEUMONIA. II3
examination of the brain was made in this case ; and I think
that this was the probable cause of death.
Apart from meningitis, paralysis of cerebral origin, generally
hemiplegic, but sometimes monoplegic, occasionally occurs in
pneumonia, either early in the disease or during convalescence.
In some of these cases of hemiplegia no gross lesion is found
after death, and they are often attributed to the effects of toxins.^
In those cases in which there is a post-mortem lesion, it is generally
softening from embolism or thrombosis. Probably in some cases
reported as without lesion a patch of recent softening has escaped
notice, which, if it is small, is quite possible.
General Pneumococctc Infection — Thrombosis of Vessels, The
patient, E. C, was a horse-driver, aet. 23, who had never had a
day's illness previously. The illness began with pain in the head
on May 5th, followed on 6th by purulent discharge from the left
ear, and on the 7th by severe pain in the left side of the chest,
which interfered with respiration, and by vomiting. He was
admitted to hospital on May 8th with well-marked signs of
pneumonia of the lower lobe of the left lung. The heart was
normal, the area of dulness not increased, and the pulmonary
second sound well accentuated. Pulse 80 ; respiration rate 60 ;
temperature 102.5°; leucocytes 18,750 to c.mm. Urine con-
tained no sugar or albumin. Chlorides greatly deficient. He
went on fairly well until the eighth day, when he had a rigor, and
his temperature rose to 105°. It was noticed that his neck was
swollen, and that there was thrombosis of the left median basilic
vein extending into the basilic and median cephalic veins, the
left forearm being swollen. The leucocyte count was now 25,700
to c.mm. ; erythrocytes 4,000,000 ; haemoglobin 90 per cent.
The following three days the temperature was normal, and
the patient felt much better. On the twelfth day the temperature
suddenly rose again to 105°. On this day a culture made from
blood taken from the right arm showed a pure growth of pneumo-
cocci. During the next few days the patient felt better, in spite
of the high range of temperature. Further, his tongue was red
and dry, and his pulse, which had previously been about 68 — 72,
now varied from 116 — 124. Leucocytes 21,800 to c.mm. The
physical signs at the left base indicated that the consolidation was
slowly clearing up in spite of the grave constitutional symptoms.
On the twenty-second day of the illness 5 cc. of antipneumo-
coccic serum were injected. On the previous day he had had
another rigor, and rise of temperature to 105°. The leucocyte
count was now 19,375 to c.mm. A trace of albumin had appeared
in the urine, which also gave a distinct band of urobilin.
On the twenty-fourth day, as the fever still continued high
and the rigors recurred daily, a second injection of 5 cc. serum
was given, with no appreciable effect, unless a fall of temperature
from 103° to 101° be so reckoned.
9
Vol. XXV. No. 96. • r^ T
Digitized by VjOOQIC
114 I>R- J- MICHELL CLARKE
There had been no extension of the thrombosis in the veins
of the left arm, which remained Umited to the veins in which it
first appeared. No other thrombosed veins were detected else-
where. There was no enlargement of the spleen that could be
detected clinically at any period of the illness. The physical
signs in the lungs remained stationary, the consolidation only
partly clearing up.
On the twenty-eighth day of the disease the temperature was
lower, at about 102°, but he was wandering in mind, looked haggard
and emaciated, was sweating profusely, had partial incontinence
of urine, and was obviously sinking. He died two days later.
The results of the post-mortem examination confirmed the
diagnosis made during life. The thrombosis here was un-
doubtedly part of a severe general pneumococcic infection, and
the gravity of the case was due to this latter condition, and not
to the thrombosis, which could only be considered an incident in
the illness, and not contributing to the lethal result.
Endocarditis. — Double Pneumonia. Maurice Y., aet. 19,
engine cleaner. There was no history of any previous illness.
For a few weeks the patient had suffered from an obstinate cold
in the head, when on October 5th he was taken with pain in the
right side of the chest, cough, fever and profuse sweats. He
went to bed, and the next day the symptoms had increased, and
he coughed up some rusty, tenacious sputum.
He was admitted on October 9th with well-marked signs of
consolidation of the lower lobe of the right lung, and there was
also dulness and bronchial breathing at the left base. The heart's
apex was in the normal position, and the area of cardiac dulness
normal. No murmur was heard. The temperature was 103° ;
pulse 90 ; respiration 30, shallow and irregular.
On October loth the signs at the left base had increased, and
now indicated extensive consolidation of the lower lobe of the
left lung. A pleuritic rub was audible all over this lobe, and there
was also well-marked pleuro-pericardial friction. The tempera-
ture was 102° on this and the following day, October nth, when
his pulse was 130, respiration 50. No cardiac murmur could be
heard, possibly on account of the loud friction sounds which were
present throughout. On this day he became suddenly worse
after a violent fit of coughing, was deeply cyanosed, and died of
heart failure.
Post-mortem. — ^There was extensive acute pleurisy over the
whole of both lungs. Nearly the whole of the right lung was
in a state of red, passing in places into grey, consolidation, and
the lower lobe of the left showed red hepatisation. The heart
cavities were dilated, especially on the right side. On the mitral
valves were some old granulations, and in addition on these and
on the edge of the valve segments were numerous recent small
granulations. Scrapings of the cut surface of the consolidated
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ON COMPLICATIONS OF PNEUMONIA. II5
lung showed numbers of pneumococci, which were also obtained
from the recent granulations on the mitral valve. The other
cardiac valves were healthy.
Endocarditis is not a common complication of pneumonia.
In the form of which the preceding case is an example it often
goes unrecognised. In this case there was no evidence from the
previous history or symptoms of the old existing lesion of mitral
valve, and, further, there were no signs of the acute endocarditis
supervening on this old lesion of the valve during the fatal illness.
Any mitral murmur during this illness would have been effectually
concealed by the loud friction sounds. The low temperature
throughout such a severe attack of pneumonia is an unfavourable
symptom, indicating poor powers of resistance on the part of the
patient. Endocarditis in pneumonia generally affects the left
side of the heart, and the pneumococcus is usually the active
agent. As to its frequency, Preble, from an exhaustive analysis
of over 20,000 cases, gives it as i per cent, of all and 5 per cent,
of fatal causes. Pneumococcic endocarditis is frequently
accompanied by meningitis, so that cerebral symptoms may
form the predominant feature of the illness. Both this and the
following case illustrate the well-established fact that cardiac
valves which are the seat of previous disease are especially
liable to be attacked by the micro-organisms of any subsequent
acute infection.
Pneumococcic (Ulcerative) Endocarditis. — Charles M., act. 47,
a clerk, had scarlet fever as a child, and at the age of 22 was told
by a medical man that he had heart disease. Except for occasional
attacks of palpitation he remained well, and was able to do his
work until April, 1900, when he was laid up with fever, cough,
and pain in the right side, and was treated for a ** liver attack."
After this he got about again, but felt weak, and six weeks before
admission took to bed on account of increasing weakness. He
had a rise of temperature every evening, with profuse sweats
between 3 and 6 a.m. There were no other symptoms, except a
slight attack of haematuria three weeks before admission, and a
rash consisting of bright red spots over the legs.
On admission he looked ill, and was anaemic and sallow. The
temperature was 102° ; the pulse 96, collapsing ; respiration 26.
There was a fading purpuric rash on the legs.
On examination the breath sounds were harsh, the lungs
otherwise normal. The heart was much enlarged, the apex beat
Digitized by VjOOQIC
Jl6 DR. J. MICHELL CLARKE
being two inches outside the left nipple. There was a marked
diastolic thrill at the apex, and a loud systolic murmur there.
At the base there was also a rough systolic murmur, followed by
a long soft diastolic murmur conducted down the sternum. All
the visible arteries showed marked pulsation, and capillary pulsa-
tion was also observed. The urine contained a little blood and
albumin. The liver was slightly enlarged. The spleen was
distinctly enlarged, its tip being felt about two inches below the
lower border of the ribs. There were no retinal hemorrhages,
and the optic discs were normal.
The temperature chart shows the irregular course of the fever,
and the high range to which it reached. There were profuse
nocturnal sweats. The symptoms and physical signs made the
diagnosis of malignant endocarditis obvious. Blood was with-
drawn from the veins of the arm on three occasions, in order if
possible to ascertain the cause of the infection, but no micro-
organisms could be recovered from it. At this time the history
of the beginning of the illness, when he was treated for '* liver
complaint," did not have the significance which it afterwards
obtained in the light of the pathological findings. In the absence
of evidence of the organism present, it was thought advisable to
try anti-streptococcic serum. Three brands of serum were em-
ployed, one of them being a polyvalent anti-streptococcic serum,
and were given in doses of from lo — 30 cc. In all 480 cc. were
injected, so that a thorough trial of the serum was made. Neither
•of them had any appreciable effect either for bad or good, except
for occasional local redness, infiltration, and tenderness at the
site of injection.
He grew steadily worse, and on October 15 th slight general
anasarca and ascites appeared. This gradually increased, and
cedema of the ankles was marked on October 22nd.
On October 26th there was thrombosis of the superficial veins
of the right calf, and a fresh petechial eruption appeared over
the left thigh and knee. The albumin in the urine increased.
About this date he became much weaker and delirious at night.
The heart's action became weaker and very irregulstr. The
murmurs persisted as at first.
On October 30th there were signs of a little fluid in the pleural
cavities and congestion of the bases of the lungs. He died on
November 4th.
Post-mortem. — ^There was a large infarct into the upper lobe
of right lung. The lower lobe of the left lung was completely
airless, dark red, solid, and granular on section. The heart was
greatly enlarged ; both ventricles much dilated. On the auricular
surface and free borders of the tricuspid valve segments were
large masses of fungating, soft granulations, which extended on
to the chordae tendineae. The mitral valves were much thickened
and contracted, but contained no granulations. The pulmonary
Digitized by VjOOQIC
ON COMPLICATIONS OF PNEUMONIA. II7
valves were normal. Aortic valves were largely destroyed, one
segment almost entirely, and covered by large masses of granula-
tion tissue. Scrapings from the valves, from the spleen, and
from the pulmonary lesions showed abundant pneumococci,
which were also stained in situ in sections made of the granulation'
tissue on the cardiac valves. The kidneys showed subacute
nephritis, and there were a few small hemorrhagic infarcts in the
jejunum.
There was no ground for the employment of anti-streptococcic
serum in this case beyond the fact that a streptococcus is the
most common cause of malignant edocarditis, and in the failure
of all attempts to determine the exact organism present, and in
view of the grave character of the illness, it was thought right to
act on the hypothesis that this organism might be present. It
shows, however, the fallacy of employing any serum in the absence
of exact evidence of the kind of organism causing an infective
illness. Looking back in the light of the post-mortem, the ** liver
attack " of the preceding April was probably a mild attack of
pneumonia, but the history was too inconclusive for us to be able
to come to any such conclusion during life.
Nephritis. — E. P., aet. lo. The patient's mother was taken
ill with pneumonia on May 13th, and her father on June 2nd.
The patient's illness began on June 6th with pain in the side,
cough, fever, sickness, and diarrhoea. She did not sleep in the
same room with her parents. She was admitted to the hospital
on June 13th. She had not passed any urine for forty-eight
hours before admission, and what was passed just before this
period of suppression was the colour of blood. She was delirious
at night.
On admission the temperature was 103°, pulse rate 104,
respiration 42. The tongue was thickly furred. On examining
the chest, there was pneumonic consolidation of the lower lobe
of the right lung. The heart's apex beat was in the fourth space,
and the cardiac dulness extended half an inch over the right
border of the sternum. There were no murmurs. There was no
enlargement of either liver or spleen. A leucocyte count gave
28,900 to c.mm. A few ounces of urine were passed, which
contained a large quantity of albumin, much blood, and blood
and epithelial casts.
On June 15th — i6th (ninth and tenth days of disease) she
was delirious, with a temperature rising to 104°, pulse 112,
respiration 44. The abdomen was swollen and tense ; the urine
showed the same characters as above. Pallor of face and pufiiness
of lower eyelids were marked.
Digitized by VjOOQIC
Il8 DR. J. MICHELL CLARKE.
On the eleventh and twelfth days of the illness the crisis
occurred, and on the following days the affected lung showed
signs of resolution. Respiration feU to 24, and pulse to 72.
On June 20th (fourteenth day of illness) urine contained blood ;
epithelial, blood and leucocyte casts, with ctystals of uric acid ;
there was stiU a large amount of albumin. Quantity passed,
32 ounces ; urea in 24 hours, 26.5 grms. A leucocyte count on this
day gave 28,000 to c.mm., and on June 26th 20,400 per c.mm.
Between June 20th and 26th the daily quantity of urine was
only 16 to 20 ounces ; on the latter date its sp. gr. was 1020, with
no blood, no casts, and only a small quantity of albumin. The
lung continued to undergo normal resolution, and by July 9th
the mischief there had cleared up. On this day examination of
the urine gave : quantity 24 ounces ; sp. gr. 1020 ; urea daily
excretion about 15 grms. on a milk diet with one egg ; a trace of
albumin only ; uric acid and calcium oxalate crystals, epithelial
cells from urinary passages, and a few granular casts.
On July 17th and 24th the face was puffy, and there was still
a trace of albumin in the urine ; otherwise the child seemed well.
At the end of this month the urine was passed in normal amount
with a sp. gr. of 1020 ; it contained no albumin and no deposit,
and she was discharged well on August 5th.
No pneumococci were found at any time in the urinary deposit.
Nephritis is a very rare consequence of pneiunonia. This is the
only case I have ever seen. I think there can be no doubt of
cause and effect in this case. In so completely and quickly clear-
ing up, it followed the usual course of nephritis in acute infective
disease. The case is a good instance of infective pneumonia, and
in the infective form, the disease is well known to be more severe,
more apt to be a general infection, and therefore to lead to com-
plications.
Pneumonia, Empyema, Arthritis. — Victor R., aet. 8, previously
healthy. On April i6th, 1906, patient fell into a pool of water ;
on the 17th pains in the right hypochondrium and side of chest,
followed on i8th by cough and pains in the left arm.
On 2ist he was admitted into the hospital with a temperature
of 102°, pulse 120, respiration 34. On examining the chest there
was dulness, deficient air entry, a few moist crepitations, and
increased vocal resonance over the base of the right lung. The
other organs were normal. The left elbow-joint was swollen, red,
and painful, and there was some fluctuation in the joint. On
April 23rd there was a patch of bronchial breathing at the lower
angle of the right scapula, otherwise the lung signs remained the
same. The swelling of the elbow-joint also remained stationary ;
the pain was relieved by placing it upon a splint. The signs of
Digitized by VjOOQIC
ON COMPLICATIONS OF PNEUMONIA.
119
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Case of Pneumococcic Nephritis.
To show range of temperature in case of Pneumococcic
(Malignant) Endocarditis.
Digitized by VjOOQIC
Digitized by VjOOQIC
Digitized by VjOOQIC
122 DR F. PERCY ELLIOTT
of haemophilia. No hemorrhage had occurred during preg-
nancy.
The present labour began on March 3rd and was preceded by
sharp uterine hemorrhage shortly before the '* pains " began.
The patient was first seen at 9 p.m., and the state of affairs then
was as follows : feeble and irregular labour pains, slight bleeding,
OS dilated sufficiently to admit one finger, lower margin of placenta
overlapping os, position of foetus normal, pulse normal, general
condition of patient good.
At 11.30 p.m. on the same day profuse hemorrhage occurred.
At this time labour pains were strong and frequent. The os
admitted the tips of three fingers. The pulse rate had risen to
120. It was decided to turn and deliver the child. Under
chloroform the os was gradually dilated with the fingers and
hand, and the child turned and delivered. Delivery took place
at 12.45 a.m., the child being alive and full term. Very little
bleeding occurred during dilation and version, and ceased as soon
as the first leg was brought down through the os. Immediately
on delivery of the child sharp bleeding followed, and the uterus
then began to show signs of inertia. The pulse rate had risen to
130 when the child was born, and with this further bleeding soon
reached 140. Manual compression of the aorta, however, im-
mediately stopped the bleeding, and with returning uterine
contractions the placenta was expressed, and without difficulty,
half an hour after delivery of the child. The uterine cavity was
then explored and emptied of a few blood-clots. There were no
placental remains. The cervix was not torn through. After the
uterus was emptied, and a drachm of ergot and some nourishment
were given, a little friction soon succeeded in getting the uterus
firmly contracted. The general condition of the patient had,
however, become very serious. Her pulse had risen to between
140 and 150, and was threadlike. She was very pale, and com-
plained of coldness, faintness and nausea. She was quickly
packed with hot-water bottles, covered with blankets, and her
head lowered. As soon as nausea became less, more nourishment
was given and retained. Compression of the aorta was relin-
quished soon after the uterus had become firmly contracted.
Three hours after delivery there was marked improvement in
all the symptoms. The pulse had dropped to 120, was much
stronger, and there was no faintness or nausea. The face had
regained some colour, the patient was warm and had taken about
half a pint of nourishment and' retained it all. She complained
chiefly of thirst and tiredness. The uterus was still firmly con-
tracted, and no bleeding had occurred since compression of the
aorta had been discontinued.
At 10 a.m. her condition again became very serious. Bleeding
had returned shortly before this, and the uterus had become large
and flabby. Alarming symptoms of shock were now present.
Digitized by VjOOQIC
ON TREATMENT OF POST-PARTUM HEMORRHAGE. 123
The pulse at the wrist was scarcely perceptible, and too rapid to
be counted. The patient complained of being cold and faint,
her body being covered with clammy sweat. She soon began to
get very restless, and to throw her arms about and cry for air.
She then suddenly became cyanosed, had a convulsion and be-
came unconscious. An hypodermic injection of strichnine was
immediately given, and in a few minutes consciousness returned,
but lasted only momentarily, the patient relapsing into a comatose
condition, her pulse now disappearing at the wrist and respiration
ceasing. The uterus, which extended above the navel and was
full of blood-clots, was in the meantime emptied and compressed
through the abdominal walls. There was no response to stimula-
tion, and no time was lost in applying pressure to the abdominal
aorta. Respiration had just stopped when the aorta was com-
pressed, and this blood-vessel could be felt pulsating feebly.
Pressure was applied with the clenched fist through the ab-
dominal walls and the uterus.
Respiration began again in less than a minute after the aorta
was compressed. Subcutaneous transfusion of normal salt
solution was then begun. While transfusion and compression of
the aorta were being carried out, the patient's legs were elevated
and firmly bandaged from the insteps to the groins, and a
hypodermic injection of " emu tin " was administered. The
head of the patient, already low, was further lowered by elevating
the foot of the bed on two chairs. A pint of saline fluid was
rapidly transfused beneath the skin of the inframammary region
on one side, and a similar quantity in the same region of the other
side. The site of injection was then changed to the right flank,
as both inframammary regions were bulging with fluid, owing to
rapid transfusion and slow absorption. The aorta began to fill
out when about a pint of fluid had been absorbed, and before two
pints of fluid had been absorbed the patient regained conscious-
ness, and the aorta could be felt pulsating strongly against the
fist. Coincidently with the rise in blood-pressure, improvement
in all the symptoms took place, the pulse reappearing at the
wrist when between two and three pints of fluid had been absorbed.
The patient then complained of being hot and thirsty, and soon
began to perspire. As soon as consciousness was fully restored,
friction and compression were applied to the uterus, and the
relaxed organ then responded quickly, although these measures
previous to compression of the aorta failed to produce contraction.
Pressure was then applied through the abdominal wall directly
on the aorta. For five hours life ebbed and flowed in a most
remarkable way. During the whole of this time compression of
the aorta was kept up continuously by my assistant and myself.
After the pulse had reappeared at the wrist transfusion was
carried on intermittently, as the tendency to relapse from shock
threatened. At 6 p.m. the state of affairs had materially
Digitized by VjOOQIC
124 I>R- F* PERCY ELLIOTT
improved. The pulse had got down to 130, and was fairly full.
The uterus was firmly contracted, and had shown no tendency
to relaxation again. Not a single drop of blood had escaped per
vaginam since compression of the aorta had been applied, and
the uterus had been finally got to contract, and this, notwith-
standing the fact that the uterus had been repeatedly squeezed
to ascertain whether any blood was escaping in utero. The
patient complained now chiefly of pain in her legs due to con-
striction of the bandages, and also of great thirst and weariness.
Since she had become conscious about 6 oz. of nourishment had
been taken, and this had all been retained. Transfusion was
entirely stopped at 6 p.m. During five and a half hours between
ten and twelve pints of fluid were transfused. The needle was
not removed from the flank until transfusion was finished, the
receiver full of fluid being kept at the same level as the flank
when transfusion was temporarily suspended. After removing
the needle a piece of adhesive plaster was placed over the wound,
about two pints of fluid being still unabsorbed when the needle
was removed.
The legs of the patient were kept suspended for about half an
hour altogether.
Between 11 and 12 p.m. the condition of the patient was
eminently satisfactory. The pulse had got down to 100, and was
strong and fairly full. The uterus was firmly contracted, and
the diaper, which had been applied immediately after compression
of the aorta and emptying of the uterus at 11.30 a.m., was un-
soiled. All saline fluid had been absorbed. The patient had
slept, taken and retained all nourishment, and had regained some
colour. She complained, however, of great pain in her legs and
of insatiable thirst. Otherwise she said she felt altogether better.
The bandages were then very carefully removed, and save for
pain and throbbing in her legs, no ill effects followed removal.
The legs had been kept warm by hot-water bottles ; the foot of
the bed was still kept elevated. The patient was left about an
hour after removal of the bandages, and from every point of
view was in a very satisfactory condition.
What promised to be a remarkable recovery from post-partum
hemorrhage and shock terminated unfortunately in a most un-
expected and tragic manner. At 2 a.m., the patient craving for
drink, and finding she was refused more than the prescribed
quantity, watched her opportunity, and the nurses leaving her
bedside for a moment, she sprang out of bed for some water on
a table near, and fell in a collapsed state on the floor. In spite
of everything, she soon succumbed to heart failure. At the time
of death the uterus was still firmly contracted, and less than a
tablespoonful of blood had escaped per vaginam since she was
seen at midnight.
Remarks. — Although this patient died, the great value of
Digitized by VjOOQIC
ON TKEATMENT OF POST-PARTUM HEMORRHAGE. 125
compression of the aorta was well illustrated. The immediate
cause of death was undoubtedly heart failure consequent on the
exertion in getting suddenly out of bed, and sudden heart failure
is by no means uncommon, even after far less hemorrhage and
shock than occurred in this case. Bleeding had ceased for nearly
fourteen hours before the patient died, and at the time of death
no further bleeding took place. Shock also was being rapidly
recovered from.
It is quite obvious in the circumstances attending this case,
at the time when compression of the aorta was adopted the second
time, that none of the methods of treating atonic post-partum
hemorrhage advocated in text-books could have been relied on
here for rescuing the patient from immediate death. The patient
must have died before plugging of the uterus or the application
of perchloride of iron could have been performed, even if these
means would eventually have stopped bleeding, a result which
admittedly is not always obtained. Compression of the uterus itself
in the manner advocated by Dr. Herman' would, if carried out
continuously for some hours, have prevented further bleeding.
But compression of the uterus by this method (which is un-
doubtedly the best) cannot be carried out continuously for any
great length of time, a fact which Dr. Herman himself admits.^
Further loss of even a small quantity of blood, as must have
occurred in changing compression with an assistant and in again
changing when the latter became tired, was a matter of vital
importance during at least the four first hours that the aorta was
compressed. During this period the patient repeatedly relapsed
in spite of no bleeding taking place, and the uterus also relaxed
from time to time. Had compression of the uterus been employed,
unless the compression had taken place continuously for about
four hours, further bleeding would have occurred, and the patient
would have died very quickly.
Although immediate and continued control of hemorrhage
was a sine qua non, prompt treatment of collapse from post-
hemorrhagic shock was of equally vital importance. Plugging of
the uterus, the injection of a styptic, compression of the uterus,
not any of these would have remedied collapse quickly enough.
Compression of the aorta not only immediately stopped all
^ Practitioner, 1907, Ixxviii. 445, ^ Difficult Labour, 1901, p. 336.
Digitized by VjOOQIC
126 TREATMENT OF POST-PARTUM HEMORRHAGE.
bleeding, but also immediately influenced shock by cutting off
the blood supply in the lower extremities, and so increasing the
amount of blood in the heart, lungs and nerve centres. Elevation
of the pelvis probably contributed greatly in this case. By this
procedure, not only was venous bleeding controlled, but the blood
supply to the vital centres was also maintained. The vis a tergo
in the arterial circulation being also diminished was an important
factor in helping to prevent hemorrhage after compression of the
aorta ceased. Saline transfusion subcutaneously no doubt
assisted materially, but without compression of the aorta would
have been useless, as even with the bleeding stopped absorption
was at first extremely slow, and could not have occurred at all
had the bleeding not been instantly checked. Intra-venous
injection of saline fluid might have succeeded, but retention of
blood-plasma was of far greater value in restoring energy than
would have been the introduction of mere salt solution.
Of the. objections raised to compression of the aorta in the
recent discussion, all had to be considered in this case with the
exception of obesity. The other objections put forward were
the intervention of a large uterus, inability to maintain efficient
compression of the aorta, ^ damage of the sympathetic nervous
system, compression of the vena cava,* and injury to the uterine
muscle from cutting off its blood supply via the uterine arteries.*
Although this patient was not obese, she possessed unusually
well-developed abdominal muscles, and in addition was highly
neurotic. When the hand was placed on the abdomen to feel the
uterus, previous to giving the anaesthetic, it was impossible to
define the outline of the uterus properly, so great was the rigidity
of the abdominal muscles. The contrast after delivery, even
after the effect of the anaesthetic had disappeared, was remarkable,
and was still more so when death was impending. There was,
therefore, no difficulty whatever in reaching the aorta when this
became necessary, although the patient when she became con*
scious strongly resented the proceeding. The intervention of a
large uterus did not in the least prevent compression being
1 Fitzgerald, Practitioner, 1906, Ixxvii. 652.
« Duke, Brit, M, /., 1907, i. 290. ^ Fitzgerald, loc, cit.
Digitized by VjOOQIC
LUPUS VULGARIS. I27
properly carried out, the uterus being as soft as " wet wash-
leather." The fact that my assistant and myself were able to
maintain efficient compression for five hours continuously is
suf&cient proof of the ability to maintain the necessary force long
enough for effectually controlling hemorrhage. In changing
compression the fist to be applied was always firmly applied on
the blood-vessel below the other fist, and by this manoeuvre no
blood was lost in changing pressure. Injury to the sympathetic
nerves, and compression of the vena cava were avoided in the
one case by changing the point of pressure from time to time
along the available part of the aorta, in the other by swaying the
fist sideways before finally compressing the aorta. So far as
could be discovered, no harm resulted in either direction.
In regard to the alleged injury to the uterus in interfering
with its blood supply, quite enough blood was carried by the
ovarian arteries for the nutrition of the uterine muscle, as the
uterus contracted and retracted not long after compressing the
aorta, and continued to do so up to the time of death. The fact
that no bleeding occurred in spite of the blood-flow in the ovarian
arteries continuing, proves the unimportance of considering these
vessels as contributing to hemorrhage after labour.
EIGHTY CASES OF LUPUS VULGARIS.^
BY
W. Kenneth Wills, M.D.,
Physician in Charge of the Skin Department, Bristol General Hospital,
One of the most difficult problems in medicine is the correct
estimation of the value of any new method of treatment which
is not absolutely specific. Not only is enthusiasm liable to run
riot at the incidence of a series of successful cases, but the reverse
may also occur, and undue depreciation of the value of a useful
method be engendered by an initial series of unsuccessful cases.
* Read before the Bristol Medico-Chirurgical Society, December 12th, 1906.
Digitized by VjOOQIC
128 DR. W. KENNETH WILLS
In attempting to make a personal estimate of the value of
radio-therapeutic methods in the treatment of lupus vulgaris,
several difficulties presented themselves at the offset.
It was claimed for the Finsen Light treatment that the ra)^
which were curative in prbperty were those rays of short but
rapid wave-length in the blue and violet, and beyond the violet
end of the spectrum. But it was soon shown that the penetra-
tion of these rays was of the smallest character, while I myself
have shown that rays of the less therapeutic value in the spectrum
pass with ease through the body. The first difficulty I met with
was in choosing the cases which would be best suited for the
treatment, out of the numerous cases which presented themselves
at the department. For the most part these were of the most
unpromising nature for any new method of treatment — the
subjects of old-standing disease, in some cases over forty years
in duration, with a history of numerous operations, many of whom
presented deep and extensively scarred lupus of the integument
with free involvement of mucous membranes.
Secondly, it soon became obvious that there were nearly as
many types of the disease as there were patients to suffer from
them. And success or failure in one case could hardly be claimed
as experience in the next.
Thirdly, the patients were largely of the " night-bird " order,
creeping out after night-fall or swathing up their disfigurements
in light-proof veils and wraps, leading thus an unhealthy and
unnatural existence, often in great want owing to the inability to
obtain even the scantiest livelihood.
As an instance of how this factor has a bearing on the estima-
tion of value of the treatment, I may cite the case of a man who
was obtaining the scantiest livelihood by selling newspapers — ^his
face always hidden under a scarf — poor to destitution, but in-
dependent. I attempted his relief by means of radio-therapy
with no good result. Some years after I happened to meet him,
and urged him again to come for treatment. He came, and in order
to do so, went into the workhouse, and obtained there better diet,
regime and attention. Instantly we obtained a most promising
effect, and the amelioration is continuing in a most remarkable way.
Digitized by VjOOQIC
ON EIGHTY CASES OF LUPUS VULGARIS. I29
Although aware of these difficulties, I thought that I would
at first restrict the treatment of the exterior at any rate to the
radio-therapeutic methods alone, and attempt to estimate the
value per se of the radio-therapeutics as]a specific. If some cases
seem to have been a very long while under treatment, it must be
remembered that until quite recently no other treatment was
used in conjunction with the light, that many of these were old
scarred cases, and some of them cases on which the Finsen treat-
ment was merely wasted.
The first case of lupus was treated in the department in
December, 1901. Up till the end of 1905 we have a record of
over eighty cases of lupus. Besides these there have been not a
few instances of other manifestations of cutaneous tubercular
disease, such as scrofulodermia, tubercular abscesses, verruca
necrogenica and the allied verrucous condition on the hands of
butchers, which is in all probability tubercular. These might
very well form a separate note, since they have been extremely
ready to respond to radio-therapy, more so than lupus vulgaris,
but I have omitted them from this collection.
The variations in type of lupus are numerous but not always
well defined, one type merging into another according to the
reaction of the patient to the disease. I have divided off the
following : —
1. Extensive erythematous forms, spreading widely and
rapidly at intervals, sometimes more or less symmetrical in
position, depending upon unknown factors for their delimitation.
Perhaps nerve areas are roughly mapped out ; certainly the
hairy areas seem to offer great resistance.
2. Nodular forms, with very slight erythema occupying one
or more areas, with no suggestion of nerve area or symmetry ;
no tendency to ulceration, and of very slow growth.
3. Hypertrophic forms (lupus exedens), with high -raised
granulation tissue, of rapid development and spread.
4. Ulcerative forms, where ulceration is the chief feature of
the case, not merely an incident in the case.
5. Verrucous forms, indolent in growth, very chronic and
resistant.
10
Vol. XXV. No. 96. . Por^alo
Digitized by VjOOQ IC
130 DR. W. KENNETH WILLS
6. Oedematous forms, with lymph-stasis out of all por-
portion to the amount of disease, but the cutaneous exanthem
showing definite " apple-jelly " nodules.
7. Sclerodermic forms.
As I have said, these types may overlap, it being difficult to
classify some cases under any of these headings. But in general
the case is true to its own type, whatever that type may be. If
it is hypertrophic on the face, it will be hypertrophic on the
hand ; if nodular on the thigh, it will be nodular on the ear ; and
so on. It is rare to find also lupus in one patch while there is
some indefinite scrofulodermia elsewhere. It would appear that
the type of disease is the expression of the tissue resistance rather
than the virulence of the strain. At the same time it is quite
rare to find phthisis in a lupus patient. It is present in a very
chronic fibroid form in three out of our eighty cases — ^3.75 per
cent. Other forms of tubercle may be present, though not com-
monly. Tubercular dactylitis in three cases — ^3.25 per cent.
Hip-disease (old) in one — 1.25 per cent. Enlarged glands in
several.
Lacrymal dacryocystitis and abscess is fairly frequent when
the nasal mucous membrane is attacked. It is of interest to note
how many patients with lupus of the face have attending infection
of the nasal mucous membrane. Indeed it is not infrequent for
the patient to admit having had a liability to epistaxis and coryza
or blocked nostril for a long period before lupus has developed
externally.
The various types behave differently to the radio-therapeutic
measures. The extensive erythematous forms are very difficult
to treat. It requires long-continued patient care to make any
headway at all with the light, and with the X-rays many and
frequent applications are necessary before the erythema dies
away and scar tissue is revealed.
As soon as this paling of the area is observed, it will be noticed
that broad bands of white supple scar tissue leave between them
islands of erythematous material, which gives the diffuse staining
characteristic of this kind of lupus through the diascope. The
X-ray treatment must be continued for a long while after this.
Digitized by VjOOQIC
ON EIGHTY CASES OF LUPUS VULGARIS. I3I
and it is this feature which opens up an avenue of danger in persons
past the middle age. Long-continued X-ray treatment in a case
where scarring is extensive, and is cutting off islands of inflanmia-
tory material, may be followed by the development of carcinoma.
It is recognised that carcinoma may develop on an untreated
lupus, the reparative processes of nature pursuing the same course,
but there is obviously a danger of raising these undesirable
statistics by the too rapid encouragement of this healing process.
Epithelioma developed on the lip in one very extensive case of
this form of the disease, and in spite of extensive removal, which
Mr. Hey Groves was good enough to undertake, the patient went
from bad to worse and died.
It is jumping to conclusions to state with any degree of definite-
ness that this was produced by the ray-treatment, but having
watched the case for years there is a haunting conviction that
the treatment was a contributary cause.
Perhaps one attempted to do too much. In the initial stages
of the treatment the light produced a great amelioration of hi?
distressing condition. Later, as the light did not seem to be
curing any part, I added the X-rays. Improvement and the
scarring of large areas was soon observed, and I was tempted to
pursue the disease wherever any recent erythema showed itself,
with this disastrous result.
On these cases an advancing edge of 'more resistant lupus is
seen as a rule. In this edge most of the recurrences will be seen
in cases which have done well, and it is necessary to treat again
and again until no fresh developments arise. On this account it
is impossible to call a case cured until years have elapsed.
The nodular forms without much erythema do well with the
light as a rule. In some cases, however, the good results are
slower to arrive than in others, and I have observed that the factor
of general health is a large one. It would seem that the reaction
to the disease in these cases is not sufficient to produce the de-
sirable erythema, which is undoubtedly reparative. Even when
this is artificially supplied the leucocytic invasion is not sufficient.
One case of this order was of a very delicate strumous type, while
a second had phthisis. In the first relief of the disease was
Digitized by VjOOQIC
132 DR. W. KENNETH WILLS
produced with some tendency to recur in spots, in the second
very little could be done. One spot only seems to have disap-
peared, while others were removed surgically, being in places
where the scars would not show. In cases where the general
health is satisfactory what erythema is present at first dies away
on the subsidence of that caused by the treatment, and the
nodules pale till they are no more than the colour of freckles, and
many disappear from view altogether. But it is not infrequent
that nodules are left behind, inveterate and persistent, and which
only the longest course of treatment might be expected to relieve.
On the other hand, the nodules are clearly demonstrated as the
focus of the disease, and the simple and not very painful process
of stabbing them with, a pointed match-stick dipped in pure
carbolic acid will get rid of them, even if it leaves behind small
pitted scars. This is the course I adopt now when I have to deal
with any of these inveterate and chronic cases. It may certainly
be claimed for radio-therapy that it decreases the amount of the
area to be treated with caustics eventually, while in many cases
of these inveterate forms it relieves without resort to caustics at
all.
In the hypertrophic forms it is seen at once what an enormous
advantage radio-therapy can offer. With the large masses of
granulation tissue exuberant, foul and greatly disfiguring, the
temptation to remove the whole with the sharp spoon is almost
irresistible. If this is performed great loss of tissue with irregular
deep scarring will occur, whereas the X-rays soon have a marked
effect upon the granulations, levelling them down to the skin, and
leaving a scar in no way particularly noticeable except for
occasional development of telangiectatic vessels, which have in
a few cases made a permanently red colouration of the scar.
This is possible after any prolonged X-ray treatment, and not
dependent on the kind of disease treated.
After the X-rays have reduced the hyertrophied granulation
masses, there may appear ordinary lupus nodules which persist.
These are not as a rule difficult to deal with, either by continuing
the rays or with the hght lamp.
The good effect of a course of the rays will continue for a long
Digitized by VjOOQIC
ON EIGHTY CASES OF LUPUS VULGARIS. 133
while after the rays are stopped. It is my practice to go very
slowly in these cases, to prevent if possible the development of
telangiectases by too rapid treatment. The result, as proved by
time, seems to be very satisfactory as far as my experience goes ;
but if ever any part begins to develop, for instance at the edge of
a patch or in a fresh part of the body, the production of granulation
material is extraordinary in its rapidity and amount.
In the ulcerated forms we have again an opportunity for the
X-rays to show an advance in therapeutic methods. Large, deep
and very chronic ulcers yield to their influence without added loss
of tissue or the contractures which might be expected. Not only
do they heal, but they remain healed. In very extensive cases
of the disease, where little else could be accomplished, the complete
healing of the sores has led to comfort and material well-being of
the patients. This good result can be obtained on the mucous
membranes as well as on the skin, provided the parts can be
reached by the rays without an undue exposure of nearer parts.
It is not advisable to treat the recesses of the nose with the rays
I from an X-ray tube, as the tip and alae of the nose will show
evidences of an overdose before good results can be obtained
internally. The common site of perforation and ulceration within
reach of the finger can be so treated and effectually. For internal
use X-rays can be applied by means of high frequency vacuum
tubes, which emit X-rays. I have tried this method with only
partial success.
In verrucous forms there is a hard, warty growth of the corneous
layer over each of the lupus nodules. The rays cause the corneous
layer to shed, and the nodules exposed thereby are more easily
dealt with, by other methods if desired, or by the continuation of
radio-therapy. Some very good results have occurred from
X-rays alone.
In cedematous forms the X-rays cause the oedema to subside,
and in this particular I think they supersede all other forms of
treatment. Occasionally the lymphstasis is out of all proportion
to the apparent amount of lupus present. The lips, if involved,
hang pendulous and unprotected; they ulcerate and become
useless. The leg, if involved, looks as if the subject of
Digitized by VjOOQIC
134 DR. W. KENNETH WILLS
elephantiasis ; but the oedema subsides and lupus nodules, which
previously were not obvious, become visible and can be treated.
In sclerodermic, hard and indurated forms, the X-rays soften
the induration, heal any incidental ulcers, and, as far as my
experience goes, the results are lasting.
Conclusions, — ^For the most part I have obtained better results
with the X-rays than with light ; but I believe that the Finsen
lamp is the better radio-therapeutic agent for nodular lirpus,
while the X-rays are better for h57pertrophic, ulcerated, verrucous
and sclerodermic forms.
Recurrences occur in this as in other treatments, and the cases
must be jealously watched at intervals after they are discharged
relieved. But it can be claimed that there is not the loss of tissue
attendant upon the other treatments, and consequently not a
tithe of the disfigurement resulting. On the parts of the body
beneath the clothing, where possible, excision is probably the
best available as well as the most rapid method. On the parts
that show, radio-therapeutic measures, supplemented by carbolic
acid puncture if required, will give slow but the best results.
ANALYSIS OF EIGHTY CASES OF LUPUS VULGARIS.
1. Patients in whom spots have been relieved, with no
recurrence in situ, though lupus may be present
in mucous membranes, or on other parts of the
body 20 = 25%
2. Patients discharged with great improvement .. 15 = 18.75%
3. Discharged with some improvement (ulcerations
healed, &c.) 9 = 11.25%
4. Improved; still under treatment .. .. .. 11 = 13.75%
5. Ceased treatment prematurely . . . . . . 8 = 10%
6. No improvement . . . . . . . . . . . . 6 = 7.5%
7. Recurrence after apparent relief .. .. .. 3 = 3.75%
8. Fresh development in vicinity of healed patch . . . . 2 = 2.5 %
9. Dead 6 = 7.5%
Digitized by VjOOQIC
ON EIGHTY CASES OF LUPUS VALGARIS.
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A CASE OF NARCOLEPSY.^
BY
Bertram M. H. Rogers, M.D. Oxon.,
Physician to the Royal Hospital for Sick Children and Women, Bristol,
By narcolepsy I wish you to understand a condition in which a
patient, with almost lightning-Hke rapidity, falls into a sleep
of short duration, the condition not being one of epilepsy.
The patient in whom I observed this condition was a young
lady, unmarried, of about 30 years of age. She comes of a highly
neurotic stock, chiefly, however, on the mother's side. In the
maternal family there are two brothers, one of whom took his
own life, while the other is a confirmed dipsomaniac. In a
married sister's family there is a daughter in an asylum, a son
with disseminated sclerosis, another son who wanders about the
world unable to settle to any definite work, but always expecting
to make a fortune by some hare-brained scheme, such as a mule
service between Suakim and Khartoum; another sister died of
Addison's disease, and a son, after an unfortunate circumstance
connected with the firing of big guns, became a hopeless nervous
wreck and shot himself. In the patient's own family there are
no such strong evidences of the neurotic taint, but her sisters are
all of a mild neurotic type, requiring rest cures at various times
for conditions produced by slight mental stress. The general
health of all is good, though not robust, and their mental activity
is good, all taking part in social and some in philanthropic work.
The subject of this paper is, perhaps, the most intelligent of
the daughters. She has attended various courses of lectures on
science or literature, takes in what she hears, and has composed
short stories and plays of quite a fair standard of excellence.
They are not brilliant literary efforts, but I wish to point out that
her intellectual powers are not deficient ; on the contrary, she
is actively and constantly employed in some mental exercise,
^ Read at a meeting of the Scx:iety, December 12th, 1906.
Digitized by VjOOQIC
A CASE OF NARCOLEPSY. I45
of a nature rather above the usual standard of young women who
Jiave not to earn their own living. Her general health is good,
menstrual functions normal, and her visual defects have been
corrected with glasses.
The first symptom noticed and complained of was occipital
headache. She told me that it seemed as if someone was attempt-
ing to lift her up by her back hair. I may mention that she has
a'great profusion of hair : not only is it long, but extraordinarily
thick ; in fact, it must seem to some of us who have little of that
ornament that the amount of hair many women carry must be
of great weight, especially when the arrangement of it is assisted
by puffs of various kinds. These headaches as a rule came on
in the morning, soon after or at waking, and lasted till midday,
when they disappeared. They were very intense while they
lasted, necessitating a darkened room and absolute quiet in bed.
There never was any vomiting, and the retinae presented no
changes. After the headache, the patient was quite well for the
rest of the day ; could go out for a walk, or bicycle a short
distance, though a greater effort might bring on a return
of the head trouble. After a week or two of almost daily
headaches sudden short lapses into sleep began. What I
observed was that on talking to her she suddenly stopped
talking, her eyelids slowly closed after twitching slightly or
screwing up of the lids, her hand went to the back of her
head, the movement being as if she was in pain, and then
with a slight turn of her head to the right she was fast asleep.
After a few minutes, or even less at times, she opened her
eyes, blinked a little, and went on with the conversation where
she left off, seldom if ever losing the thread of her conversation.
On waking she was sometimes rather excited in manner, but was
evidently quite ignorant of her lapse into sleep. This sudden
falling asleep might take place two or three times in the quarter
of an hour or more that I saw her, sometimes in the middle of
writing or drawing something, or even while eating. This, I was
told, would continue all the morning, sometimes with headache,
sometimes without, but nearly always she had a heavy sleep for
^n hour or two in the afternoon. By the evening she had nearly
II
^^OL. XXV. No. 96.
Digitized by VjOOQIC
146 DR. BERTRAM M. H. ROGERS
thrown off the condition, but might occasionally go off suddenly-
while at dinner. She slept well, almost too heavily, at nights
After a few weeks of this condition she began to lose flesh, and
her digestion got out of order. Not unnaturally, her parents-
got rather alarmed, not only about her present state, but for the-
future, and though I was able to assure them that there was
no evidence of serious mischief at the time, I was rather
anxious for the future. After a couple of months of varying
degrees of somnolence she began to improve, the first symptom
that began to give way being the headaches : these got less in
intensity and in frequency. Her parents then took her to London
to see a distinguished psychologist, but unfortunately she slept
and could not be aroused the whole time he was there. A short
time before going to London a new symptom began to show
itself — ^pain in the left iliac region, with a sort of spasm when the
somnolent state came on. A change of treatment was suggested
by the London physician, but did not appear to make much
difference, the trouble slowly but surely improving. When her
condition allowed her to be about more, she went abroad with
a sister and nurse for three months, returning quite well, having
lost all pain, all tendency to sleep at wrong times, and having
put on flesh to her normal condition.
The patient continued quite well for over two years, went
about in society without anyone noticing that anything had been
the matter, and resumed her ordinary occupations and studies,,
in which she showed considerable aptitude, following them with,
diligence and with considerable intelligence. In fact, apart from
the inherent neurotic condition, she was quite well.
The liability to narcolepsy was not, however, entirely eradi-
cated, and, as I shall show, was only dormant, for it was
reawakened by a trivial circumstance on one occasion, and by
a severe mental stress again some years after.
The first recurrence followed a slight operation which was
necessary to relieve an inflamed gland in the neck. She took
the anaesthetic well, and recovered from it without any trouble^
but on the following day the nurse told me that she had on several
occasions lapsed into sleep of short duration, a few minutes or so„
Digitized by VjOOQIC
ON A CASE OF NARCOLEPSY. I47
to wake up quite unconscious of having lost herself. This attack
was of exactly similar character to the former one, but unaccom-
panied by headache, and of a decidedly milder type. On more
than one occasion she dropped off while the surgeon and I were
in the room, waking up suddenly and continuing the conversation
where she had ceased before her sleep. This attack lasted only
a few days, but naturally caused both the family and myself
considerable anxiety as to whether the condition would improve
soon, or whether the patient was in for a long period of liability to
the attacks as before. Before the wound healed — a week or so —
she was quite well, and the symptoms of the condition passed off.
The second relapse followed, as I said, after a severe mental
strain. The patient's mother, to whom she was exceedingly
attached, died after a few days* illness away from home at a sea-
side resort. The narcoleptic condition only presented itself once
or twice. I only saw her once pass into the semi-conscious state
not amounting to actual sleep. She was sitting in a chair, when
I observed her close her eyes and appear to lose her balance for
a few moments, recovering with the blinking of the eyes that I
noticed in the first attack. Had I not known and seen the first
attack, I should hardly have recognised what the nature of it
was ; perhaps I might have thought it a passing fainting attack,
but, knowing her previous history, I have no doubt that she had
a slight recuprence.
Since this time she has been quite well, and uses her brain
considerably for work of all kinds, and as much as she has
ever done.
I have no intention of entering any further into a discussion,
or giving you an essay on this condition. A very large number
of cases have been reported in medical literature differing slightly
in details, but in the main the same as the case I have just read.
They are interesting cases. The conditions that manifest them-
selves are so peculiar and strange, and the causation and pathology
so obscure, that we carmot hope to be able to explain the pheno-
mena without further observation.
I wish only to point out that the symptoms are not in any
way aUied to epilepsy, a fact which writers on this condition lay
Digitized by VjOOQIC
148 A CASE OF NARCOLEPSY.
special emphasis, nor is the relationship to normal sleep quite
clear. Raymond, who has written on the subject, in alluding
to the pathological varieties of sleep, " mentions a condition
which would seem to represent the border-line between normal
sleep and the unconsciousness often accompanying recognisable
lesions of the cerebral structures," and perhaps this " border-
line," — a word I do not at all like — ^may be taken to be held by
this condition known as narcolepsy. He recognises a mental
hebetude and abnormal slumberous conditions associated with
disordered mental activity.
Raymond's account might have been taken from my patient.
He describes the condition as one in which the patient outside
the usual hours of sleep passes into slumber. The sleep comes
on suddenly in the midst of ordinary occupations, even, he says, as
in my case, during meals. He states it is noticed in subjects liable to
gout, rheumatism, or obesity, or suffering from auto-intoxications.
Dr. Blodgett's patient had been subject to the attacks continu-
ously for forty years, and often had several attacks in one day.
She fell into a perfectly natural sleep, and could be easily ronsed
by a call or an unusual noise, waking up unaware that she had
been asleep, though at times the state was more profound, and
she realised that she had passed an appreciable interval in uncon-
sciousness. In spite of these numerous attacks lasting over such
a long time, very little mental deterioration was noticed by her
friends, and it must be observed that the patient was reaching
an age when some failure might not unnaturally follow.
Other writers remark on the association of this condition with
a toxic poisoning — toxic poisoning is almost as blessed a word
as Mesopotamia — with obesity or diabetes, or deem the association
of these diseases as accidental or following the same causative
action ; but I am inclined to accept Dr. Blodgett's remark, '' No
definite information upon this causation of symptoms in narco-
lepsy is yet available." This gentleman, in the account of his
case, lays considerable stress on the neurotic history of his
patient's family. In this his case agrees with mine, for in both
there are the frequent manifestations of some neurosis taking
one form or another.
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TUMOURS AND TUBERCLE IN MONKEYS.
BY
W. Roger Williams, F.R.C.S.
Great interest attaches to the maladies of monkeys, because it is
among the highest members of this order that we find the nearest
approach in organisation to mankind.
Notwithstanding the immense number of these creatures
constantly under observation in the zoological collections of
Europe, it is a curious fact that only about half a dozen examples
of tumours have hitherto been reported ; and their comparative
immunity from this kind of malady seems to be a reality.
Thus, some time ago Bland-Sutton^ examined the bodies of
no of these animals who had died in the London zoo, but not
a single example of any tumour did he find. Subsequently,
H. J. Campbell- made 38 similar post-mortem inspections with
the like negative result.
Cancer. — Leblanc,^ however, long ago reported that he had
met with instances of malignant tumours in monkeys, and I
expect that they do occasionally occur, but I can cite only two
modern instances.
The first of these is due to Goodhart,^ who found '* cancer *'
of the pituitary body in an Anubis baboon from the London zoo,
where the animal had long been a familiar denizen. The tumour
—a large, ragged-looking object — occupied the pituitary fossa,
which it had eroded, and some of the adjacent structures were
infiltrated. Histologically, it comprised ** large epithelial-like
cells arranged in some sort of an alveolar manner.'* There were
no secondary deposits. This tumour, together with the brain
and skull, are preserved in the museum of the Royal College of
Surgeons.
' Lancet, 1883, ii. 276. ^ Guy's Hosp, Rep., 1891, xlviii. 19.
9 Clin. Vet., 1843, Aug., p. 343.
* Tr. Path. Soc, Lond., 1883, xxxvi. 36. __
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150 MR. W. ROGER WILLIAMS
The second instance was met with in a bonnet monkey, only
eight months old, by Bland-Sutton,^ the tumour being an intra-
ocular glioma, consisting chiefly of small round cells.
In this connection reference may be made to the attempts
of Metchnikoff, Shattock and Ballance and others, to transmit
human cancer experimentally to monkeys, all of which experi-
ments failed.
Thus monkeys, like human savages, seem to have very little
proclivity to cancer.
Here it may be remarked that the alimentary propensities
of these animals are predominantly frugivorous ; but a good many
of them are not averse to animal food when they can get it ;
some kinds are insectivorous, and others feed upon almost any-
thing they can get. Like mankind, many species have a singular
liking for birds and their eggs, as alimentary dainties.
Non-malignant Tumours. — With regard to non-malignant
tumours, the available data are exceptionally meagre. Bland-
Sutton has met with an instance of leio-myomatous thickening
in the uterus of a baboon, which had some resemblance to
myoma ; and the same observer has also seen a fatty, tumour-
like mass in the vicinity of each tfestis of a monkey, with
hermaphroditic malformation.
According to Otto, exostosis is not uncommon at the tip of
the tail of long-tailed monkeys ; and in the museum of the Royal
College of Surgeons of Ireland the hand of a monkey is preserved,
showing a spongy exostosis of the first phalanx of the little finger.
Monkeys are also subject to hydatid cysts.
These few examples practically exhaust our present know-
ledge of non-malignant tumours in monkeys.
Tubercle. — It is an ancient belief, that monkeys kept in
captivity are very prone to tubercle, and some years ago a mild
sensation was experienced when Bland-Sutton- flatly contra-
dicted this cherished conception. In justification of his con-
tention, he appealed to the records of no post-mortem inspections
of monkeys which had died in the London zoo, and comprised
only three instances of tubercle.
* /. Anat. &• ^ysiol.,iSSs, xix. 449. ^ Loc. ciU
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ON TUMOURS AND TUBERCLE IN MONKEYi. I5I
He found, however, that these animals had experienced very
heavy mortality from diseases of the lungs, the list comprising
21 examples of bronchitis, ii of pneumonia, &c.
Some years later, H. J. Campbells as the result of similar
work in the same field, arrived at exactly the opposite conclusion,
having found that tuberculous disease was very frequent in these
monkeys. Thus, no less than 20 of the 38 bodies he examined
presented well-marked tuberculous lesions. In addition to these,
there were also many cases of broncho-pneumonia.
It is evident that these discrepancies depend largely upon
'diversity as to the criterion of tubercle. Viewing the matter in
this light, we shall probably be right in maintaining the validity
of the old belief.
In support of this, reference may be made to the observations
of Dr. A. J. Harrison, who has long been connected with the
management of the fine collection of animals in the CHfton zoo.
He says'-: — "Monkeys are very liable to chest affections, and
there can be no question that we have lost a great many from
tuberculous disease of the lungs. They seem very prone to
pleurisy, and adhesions are frequently found with and without
tuberculous masses in the lungs, but actual cavities do not seem
to be frequent. Monkeys seem to be particularly prone to
tubercle."
It accords with the foregoing, that Lydia Rabinowitsch^ has
iately found many instances of tubercle among the monkeys that
died in the Berlin zoo ; and of 36 cases in which these lesions were
specially examined ad hoc, in nearly three-fourths the type of
tubercle was human : examples of bovine, avian and mixed types
were only occasionally met with.
It has likewise been proved, that monkeys are very susceptible
to the experimental inoculation of both the human and bovine
forms of tubercle, as the experiences of Dieulafoy, Krishaber,
Bungern and others testify.
Of like import is the common occurrence of specimens of
simian tuberculous disease in museums, such as that of the Royal
* Loc. ciU 2 Bristol M.-Chir, J., 1894, xii. 285.
^ Deutsche med, Wchnschr., 1906, xxxii. 866.
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152 PROGRESS OF THE MEDICAL SCIENCES.
College of Surgeons of Ireland, which have good collections
illustrative of the pathology of these animals.
According to Woods Hutchinson, ^ monkeys in their native
forests are but little prone to tubercle ; but in captivity it is
difficult to procure specimens free from the disease. Thus of
45 monkeys that died in captivity at the London zoo (1898 to
1899) 17 died of tubercle, or 38 per cent. Food habits have
much to do with tubercle mortality ; for of Hutchinson's animals
35 were vegetarian Catarrhines, and it was among these that
all the 17 deaths occurred ; whereas, not one of the 10 deaths
among the Platyrrhine monkeys, who had taken a fair amount
of animal food, was due to tubercle.
progress of tbe flDeMcal Sciences-
MEDICINE.
Pleural effusions present so many difficulties in diagnosis,,
that every additional symptom is welcome which really aids in
revealing their presence. In children especially the physical
signs are often hopeless, and we may be compelled to make
exploratory punctures, which are themselves by no means re-
liable, jyiuch discussion has taken place over the paravertebral
triangle of dulness on the opposite side to an effusion which was
first described by Grocco in 1902. Thayer and Fabyan*-* found
this dulness crossing the median line and extending over to the
healthy side in thirty cases out of thirty-two, one of the other
cases being an interlobar empyaema, where it could hardly be
expected to be present. Over the vertebrae themselves the dulness
is marked to about the level of the flatness caused by the effusion
on the affected side. The base of the triangle extends beyond
them for two to seven centimetres, and a line joining the end of
the base to the highest dull vertebral hypophysis forms the third
side. In this area the respiratory sounds may be suppressed, and
those sounds which are heard are tubular or nasal in character.
It is usually larger in right-sided effusions, and is particularly
valuable in encapsulated ones where the diagnosis is difiicult.
In pneumonia a similar well-marked area of dulness rarely occurs,,
and if present it does not alter or vanish when the patient lies on
'^^ ^ Human and Comparative Pathology, igoi.
r , ^ Am, J. M, Sc. , 1907, cxxxiii. 14.
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MEDICINE. 153
the affected side. In effusion, on the contrary, this dulness at
once changes with the posture. The writers think that the fluid
lies against and in front of the vertebrae and dulls the vibrations
which would be conveyed through them. Pieraccini noted a
similar but hyper-resonant area on the healthy side in a case of
pneumo- thorax. I have endeavoured to subject this last observa-
tion to a test, but though the resonance over the vertebrae was
marked, it was difficult to satisfy oneself that there was real
h}^er-resonance there, or over the healthy side in the area under
discussion.
Hypertension. — Some time ago reference was made in these
columns to the terrible mortality due to the common forms of
apoplexy, that is chiefly to cerebral hemorrhage and thrombosis.
Since that time considerable progress has been made both in the
way of prevention and treatment. The estimation of blood
pressure by exact instruments has become more common, and
much research has been devoted to the means of preventing or
reducing excessive tension. Since many cases of this over-tension
have been found unconnected with nephritis or any known disease,
efforts have been made to map out the course and tendencies of
this '* idiopathic " for<m, with the result that a fairly well-marked
group of symptoms has been recognised, though the underlying
cause is still uncertain. A theory has been put forward by Loeb *
that hypertension is an effort towards self-preservation, though
at a serious cost. The blood supply of certain parts of the
organism is an absolute necessity, and to maintain this the
pressure is automatically raised, even though other structures are
imperilled. Gushing, indeed, propounded this explanation of the
extraordinary blood tension found in compression of the brain,,
viewing it as an effort to maintain the blood supply of the
medulla. In kidney disease and other instances the rise of
pressure has been usually regarded as the result of the in Itation
of various toxins on vaso-motor nerves, or on the muscular wall
of the arterioles. Increased suprarenal secretion, lessened
thyroid activity, or excessive viscosity of the blood, have also^
been invoked as causes. Now Loeb finds that in kidney disease
hypertension appears chiefly in those forms where the glomeruli
are most affected, and he regards it as a means of maintaining
their blood supply, and hence the functional activity of the
kidneys, by a reflex which raises the general blood supply through
the cerebro-spinal centres. Similar reflexes are invoked in other
c^es of hypertension. Certainly the supply of blood to each
vital organ is all essential. In orthopncea, as Leonard Williams
says, the patient sits up to facilitate the efflux of venous blood
from the medulla. Still, there seems little direct proof of these
reflexes, and there is much to be said on the other side from the
fact that certain substances in the blood stream can without
i Deuisches Arch. f. klin. Med., 1905, Ixxxv. 348.
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154 PROGRESS OF THE MEDICAL SCIENCES
doubt act directly on the muscular coat. Arterio-sclerosis is
more often a result than a cause of high tension, as most observers
now agree, and sometimes neither this nor any other condition
can be detected as a cause. Though the patient be abstemious
and placid, with healthy kidneys and vessels, the blood pressure
may reach 200 mm. He may suffer from dyspnoea on slight
efforts, attacks of vertigo, somnolence and palpitation.^ Tlie
pulse rate shows no difference when he is standing and lying down,
the aortic second sound is accentuated and the apex displaced
outwards. Sooner or later the heart, labouring under its load,
breaks down with a leaking valve, perhaps the aorta dilates, or
a cerebral hemorrhage takes place, and the patient is killed or
crippled for life. Clearly it is important to prevent this con-
-clusion, either by discovering the cause of the evil, or, if this is
impossible, by warding off the secondary results. Benefit is often
obtained by reducing the quantity of the food, and especially the
nitrogenous elements of it, and by prohibiting tea, coffee and
tobacco. Oliver, at the meeting of the Therapeutical Society,
advocated in some cases a lacto-vegetarian diet with the exclusion
of salt. The drinking water should contain a minimum of calcium
salts. Among other vaso-depressants certain benzene derivatives
appeared to be useful. Senator- appears to rely upon similar
•dietetic treatment, and thinks that iodine preparations are chiefly
valuable from their lessening the viscosity of the blood. He
prefers to give them in combination with nitrites. Thus he
administers potassium iodide with sodium nitrite for considerable
periods. Others employ nitrites only on special emergencies, and
trust chiefly to careful diet with the frequent administration of
salines and blue pill.
Huchard-^ claims that aneurysms are best treated by thus
lowering the blood pressure, and reports some instances of success.
He employs a strict diet with a minimum of meat and extractives,
tea, coffee, stimulants, and tobacco, and enforces rest. Too much
value has, he thinks, been given to the iodides, and he would rely
more upon the use of nitrites. From time to time he gives a course
of milk diet with theobromine to ehminate vaso-constrictor toxins.
One of the most important points in connection with hyper-
tension is the treatment which should be adopted when the heart
gives way under the strain of high blood pressure, Leonard
Williams, for instance,* insists that to give heart tonics in mitral
regurgitation due to obstruction in the peripheral vessels is merely
to whip a tired horse, but that if we lower the tension the heart
will recover its tone. Evacuants, theobromine and rest in bed,
and vaso-dilators would then be our chief remedies. On the other
hand, some writers, such as T. C. Janeway,'' do not hesitate to
^ Leonard Williams, Clin. J., 1907, xxx. 29. '^ Folia Therap., 1907, i. 40.
^ /. d. Praticiens, 1906, xx. 307. * Loc. cit., p. 39.
■^ Am. J. M. Sc, 1907, cxxxiii. 54.
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ilEDICINE. 155
•employ digitalis in the failing heart due to hypertension, though
in a sudden failure' of the left ventricle Jane way advises the
simultaneous use of vaso-dilators and cardiac stimulants.
The diagnosis of typhoid. — Among other aids to diagnosis the
following have been recently under discussion. The continuous
loss of the abdominal reflex in the infra-umbilical region has been
shown by J. D. Rolleston • to have considerable value if daily exam-
ination is made for it. Out of forty-five cases which he tested, be
found it absent or diminished in forty-two, the three others not
teing examined till late in the disease. The reflex is practically
always present in young people both in health and during all other
diseases, except in certain affections of the nervous system and
abdominal states, such as appendicitis and peritonitis. Thus
Miiller and Seidelmann found it in 2,999 persons out of 3,000 who
were not suffering from those two groups of diseases. After the
age of 50 it tends to disappear even in perfect health, and therefore
it is of no use as a test for typhoid after that age. In young
people, however, the reaction obtained by stroking the abdomen
i)y a pencil disappears, or is much diminished during typhoid for
a variable period averaging a week. It is not clear how early it
is lost. At a very early stage it may be quite brisk, and then
fades away, to reappear towards the stage of lysis. If it fails to
return when the temperature is falling, a relapse may be expected,
and it is therefore of some prognostic value. A persistently high
temperature after the return of the reaction is due to some other
•cause than the typhoid itself.
A yellow pigmentation of the palms of the hands and the soles
■oi the feet is in my own experience very frequent in typhoid, and
of some diagnostic value. Though it may depend to some extent
on the occupation and personal habits of the patient, we rarely
see in other diseases the vivid colouring which is present in
typhoid. Regis- attributes its recognition to Philipowicz, who
found that it was peculiar to typhoid, and ascribed it to an
atrophic condition of the skin due to the failure of the capillary
circulation. The cause is however uncertain, but Grocco thinks it
h almost always present in typhoid, especially in children and
women, though less certain in men. It usually appears in the
first week, disappears with convalescence, but returns during a
relapse, and seems to bear no relation to the severity of the case.
Bernard describes another symptom to which he attaches some
value in childhood. If we palpate the ileo-cocal region with care,
two or three swellings will be felt varying in size from a filbert
to an almond. They are parallel to the long axis of the colon,
and are perceptible about the end of the first week. It has been
said that these swellings are hypertrophied Peyer's patches, and
they certainly seem to correspond to the situation in which the
patches are found.
^ Brain, 1906, xxix. 99. ^ M. Press and Circ, 1906, cxxxiii. 6.
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156 PROGRESS OF THE MEDICAL SCIENCES.
The presence of typhoid bacilli seems almost universal in the
secretions and fluids of the body. Thus they are found not only
in the stools, the urine and the roseolous spots, but also in the
blood, the sputa, and sometimes in the bile. Von Jaksch found
them in over 94 per cent, of the splenic punctures he made, and
claims that this method is free from danger and is the best means
of an early diagnosis. Preble v notices that more reliable resuhs
are now given by blood cultures, as the technique is improved.
He quotes Duffy as getting positive results in all his cases where
the temperature was over 102°, but less frequently when it was
lower. The difference was apparently due to the stage in the
disease, and the suggestion is made that the bacilli are always
present in the second and third week. Coleman and Buxton
find that in 604 reported cases bacilli were met with in 453, or
75 per cent. Hirsh too concludes that bacilli are always to l)e
found at some stage, but that they disappear about the end of
third week ; while Poppelmann claims to have obtained excellent
results by simply making blood smears in the ordinar>^ manner,
and staining them by the May-Grunewald method. If this is
confirmed in practice, a most valuable aid to diagnosis will be
gained.
George Parker.
SURGERY.
Several papers have been published during the last few years *^
on delayed ana^thetic poisoning, and such a condition is now well
recognised, and comes, of course, under the observation of the
surgeon in charge of the case, and not the anaesthetist. As the
symptoms are not pathognomonic, it may be extremely difficult
to say in some cases whether they have been caused by the
anaesthetic or not, and it is highly probable that in several cases
in which they have been attributed to it they have been due to
other causes. In many of the cases of late anaesthetic poisoning,
acetone or diacetic acid, or both, have been found in the urine,
and there is often a smell of acetone in the breath ; but acetoue
has been frequently found in the urine after the administration of
an anaesthetic without symptoms,^ and it is stated by Guthri^^ to
be present in " starvation, malignant cachexia, peritonitis, gastric
ulcer and other abdominal disorders, sepsis, pneumonia, aften
poisoning by phloridzin and morphine,'* as well as in diabetes,
and he says *' it may be artificially induced by the injection of
fat." Indeed, it seems to me probable that if carefully looked for
it would be found in the urine of healthy persons fairly often.
' Prog. Med., 1907, i. 175.
* Guthrie, Lancet, 1S94, i. 193 ; 1903, ii. 10 ; 1905, ii. 5S3.
3 Hubbard, Boston M. and S. J., 1905, clii. 744 ; abstract in Lancet^
1905. ii. 234.
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SURGERY. 157
Kelly^ found acetone and diacetic acid in the urine of patients
on admission to hospital suffering from various diseases who had
not had an anaesthetic, and without any symptoms Hke those of
late chloroform poisoning. Moreover, symptoms such as occur
in these cases of late chloroform poisoning may occur without any
anaesthetic or operation, and may be fatal,*"* and the condition
present in paroxysmal vomiting of children is a closely allied one.
Again, sepsis may cause similar symptoms, and it would be almost
impossible to say in a septic case that they were due to delayed
anaesthetic poisoning rather than to the absorption of a septic
toxine, though not necessarily one producing pyrexia. It is only
in cases in which the patient is in good general health at the time
of the operation, and this an aseptic one and unattended by
shock or absorption of carbolic acid from the skin, that we can
regard the anaesthetic as the cause of the symptoms. Chloroform
has been mainly responsible for such symptoms, but there are
a few cases in which they have followed the administration of
ether:' In carboluria the peculiar conditions of the urine would,
©f course, indicate the nature of the case, but the symptoms closely
resemble those of late anaesthetic poisoning. Some seem to think
those of fat embolism do also, but they certainly do not in a
t3rpical case of fat embolism.
The s5^mptoms of late anaesthetic poisoning are described by
Guthrie* as profuse and repeated vomiting, the vomit eventually
resembling the dregs of beef-tea, restlessness, excitement, delirium,
alternating into periods of apathy, occasionally jaundice, and
unconsciousness deepening into coma. The symptoms come on
about twelve hours after the anaesthesia, and in the interval the
patient may seem to be progressing favourably. Death may
occur in twelve hours, but not usually until the fifth day. There
is not usually any rise of temperature, but it may be very high.
Albumin may be present, and casts may be found in the urine also.
I have already referred to the smell of acetone in the breath.
In many of the fatal cases extreme fatty change has been
found in the liver, and also a similar change in the heart, in the
muscles, and in the kidneys, and no other condition has been
discovered associated with this. .»
It is thought by most of those who have studied this subject
that the fatty change is produced by the chloroform, and in some
way, and at any rate to some extent, is the cause of death ; but
Guthrie holds that it precedes the anaesthesia, and is only aug-
mented by it, but that this augmentation is in some way the cause
of the symptoms. If such fatty change, found after the adminis-
tration of chloroform, were caused by it alone, both the fatty
^ Kelly, Ann. Surg., 1905, xli. 161.
* Brackett, Stone and Low, Boston M. and S. J., 1904, cli. ; abstract
in Lancet, 1904, ii. 846.
^ Favill, /. Am. M. Ass., 1905, xlv. 691.' * Guthrie, Lancet, 1905, ii. 5S3.
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158 PROGRESS OF THE MEDICAL SCIENCES.
change and the resulting symptoms ought to occur in proportion
to the duration of the administration ; but they do not. Indeed,
if such fatty change were the sole cause and were due to the
anaesthetic, cases of late anaesthetic poisoning should only occur
after very prolonged anaesthesia (cases, in fact, in which an ex-
cessive dose has been given), as it is such a very rare condition.
If, therefore, the fatty change is due to the chloroform, and in any
degree causes the symptoms, there must be also some other factor
at work, and we are quite ignorant as to what this is, for there
seems to be no evidence to support Guthrie's view that fatty
degeneration of the liver precedes the administration of the
chloroform, though if it did the effect of the chloroform would be
readily explained, for it would act *' as the last straw,'* as it has.
been expressed. There is no doubt an extremely fatty liver may
be present in children who have had no anaesthetic. Dr. John
Thomson, of Edinburgh, has seen very extreme examples in
children dying of broncho-pneumonia.^
We know from experiments on animals- that subcutaneous,
injection and inhalation of chloroform will produce fatty degenera-
tion of the liver and other organs. In some of the experiments
a control examination of the liver was made under ether at an
earlier period. Ether injected subcutaneously did not produce
this fatty change in the liver, yet some of the fatal late anaesthetic
poisoning cases have been after ether, and fatty changes were
found in the liver, kidneys and muscles.* Guthrie regards such
cases as proof of pre-existing fatty change in the liver*. But
then, if' ether does not markedly increase this, how could such
fatty change, accelerated by the ether, have been the cause of
death ? It must need a very light straw indeed, as the last one,
if the ether is to be blamed at all.
In chronic tuberculosis fatty changes in the liver are quite
common, yet late anaesthetic poisoning is not specially common
in such cases.
It cannot then be regarded as proved that the fatty change
found in the liver, heart and kidneys is by itself really the cause
of death in these cases. Even granting that it is in some way
connected with the death, in what way it is so is still quite un-
certain. Neither is the relation of the symptoms to the presence
of acetone and diacetic acid clear. In fact, at the present time
the whole subject is very obscure.
The treatment adopted by some in diabetic coma has been
recommended for this condition — saline transfusion, and the
administration of bicarbonate of soda. It would seem that if it
^ Stiles and McDonald, Scottish M. and S. /., 1904, xv. 97.
2 Stiles and McDonald, loc.cit.; Ungar and Junkers, Uber fettige Entar-
tung in Folge von Chloroform-inhalationen, Bonn, 1883 ; Ostertag, Arch. /.
path. Anat., 1889, cxviii. 250; Schenk, Ztschr. /. Heilk., 1898, xix. 393.
» Carmichael and Beattie, Lancet, 1905, ii. 437. * Lancet, 1905, ii. 583.
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SURGERY. 159
is an acid poisoning it is neither acetone nor diacetic acid, but a
precursor of these — p oxybutyric acid, which is the poisonous
agent.
* * * *
The publication by Mr. Barker of a paper on '* Spinal Anaes*
thesia'' ^ has brought the subject prominently before the minds of
surgeons in this country, and it may be weU to consider the value
of this method of producing anaesthesia, as contrasted with the
ordinary one. Mr. Barker does not suggest its general adoption
in place of the usual method. He has tried it in 128 cases with a
view to determine its value, and seems well pleased with it. It
has been used in several thousand cases on the Continent by
various surgeons.
There are three questions to be answered before we can form
an opinion as to its value : —
1. Has it advantages over general anaesthesia as at present
employed ? In answering this we must consider its relative risk
to life, and the probability of unpleasant sequelae.
2. What are the Hmitations as to its use ?
3. Is it certain in its action ?
There is now nothing unpleasant to the patient in general
anaesthesia. When ether was given alone there undoubtedly was ;
but ether preceded by nitrous oxide or ethyl chloride is not un-
pleasant to take, nor is chloroform. The after taste of ether is,
however, often much complained of by patients. But, as Mr. Barker
says, some patients have a great dread of a general anaesthetic.
In what does this dread reaUy consist ? If it is fear of death from
the anaesthetic, then %ve can hardly represent to them that spinal
anaesthesia is safer on the evidence at present before us. We
should rather point out to them how seldom anyone dies from a
general anaesthetic. If it is some unreasonable fear of losing
consciousness, or dread of suffocation, then spinal anaesthesia
seems inost suitable in such cases. But many patients would,
I think, prefer to lose consciousness, and to know nothing of what
was going on. Mr. Barker tells us that those patients of his who
had had both chloroform, and spinal anaesthesia, preferred the latter.
After a general anaesthetic vomiting is, of course, sometimes
trying, though often absent, and headache may occur as well.
With stovaine both headache and vomiting may occur, and the
vomiting even occur during the operation (though this is very rare).
In Mr. Barker's second series of fifty cases, some nausea or vomiting
and headache were present in twenty, but only quite exceptionally
was vomiting marked. These symptoms were usually removed
by phenacetin and caffein^ or a purgative. The after effects of
stovaine in one hundred of Chaput's cases' were vomiting in ten
1 Brit. M. J., 1907, i. 665.
^ " L'Anesthesie rachidienne a la Stov3.mQ," Arch, de Therap., Nov. 1 5th,.
1904 ; Chiene, Scottish M. and S. J., 1906, xviii. 220.
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l6o PROGRESS OF THE MEDICAL SCIENCES.
(not always on the first day), nausea in thirteen, headache forty
times (not always on day of operation), always relieved by applica-
tion of ice. Neuralgia is said to have occurred in more than eighty
cases, but it is not stated where. This also in thirty-five cases
was later in its onset than the day of operation. When cocaine
was used, these symptoms and pain in the back were often severe,
and the after effects seemed worse than with general anaesthesia.
With stovaine it is difficult to decide. They do not, at any rate,
seem worse than the after effects of general anaesthesia.
Th^ risk to life of spinal anaesthesia does not seem great, but
there have been serious symptoms from its use, and I do not know
that we are yet in a position to compare its risks with general
anaesthesia. Tufiier up to 1904^ had no bad results in 2,000
cases. At the German Surgical Congress, 1905,- Hermes, of
Berlin, in reporting ninety cases of Sonnenberg's, said that a cold
sweat with pallor and small pulse occurred in several abdominal
operations under stovaine, and Preindlsberger, of Sarajewo, in
305 cases had six similar ones. Chaput "' describes a case in which,
after injection of stovaine from a " defective old stock," the pulse
stopped, but returned with the administration of stimulants, and
the use of artificial respiration. The ciase is quoted by Chiene*.
Silbermark had used stovaine in 300 cases, and thought that with
this drug, eucaine and tropacocaine. there was no danger ; nor
had Neugebauer observed any alarming symptoms in 480 cases.
Bier stated that the use of an adrenal preparation with the
stovaine limited its dangers considerably, and should always be
used. Septic infection of the spinal canal seems never to have
occurred in the experiences of these surgeons, and should not, of
course, occur, but might if the method were employed by those
unaccustomed to thorough methods of sterilisation. There is, at
any rate, one case on record of persistent paraplegia following
spinal cocainisation. At the Surgical Society of Paris a patient
was shown who three days after the operation began to develop
spinal symptoms, and they continued eight months later, when
the case was reported.^
Almost all surgeons who have endeavoured to produce spinal
anaesthesia have had failures, and some many failures, but it seems
generally considered that this is due to faulty technique.
Mr. Barker says it may be better not to use this method for
the very old, at £dl events for the present. But it is difficult to
know at what age persons are to be regarded as very old. Bier"
recommends it for the weak and aged; Hermes^ for patients
over 75.
Spinal anaesthesia has one distinct advantage, and that is that
^ " Anesthesie rachidienne a la Stovaine," Wien. klin. therap, Wchnschr.,
1905, No. 15.
^Ann. Surg., 1905, xlii. 942. ^* Society de Biologic, May, 1904.
* Scottish M. and S. J., 1906, xviii. 220.
s Lancet, 1905, i. 677. *^ Loc. cit, "^^Loc. cit.
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SURGERY. l6l
in an operation on the lower limb, such as a hip joint amputation,
likely to be attended by shock, it tends to prevent it, just as Crile
showed that the injection of cocaine into the large nerve trunks of
the limbs would. In a patient much exhausted by hectic fever,
I amputated just below the trochanters under stovaine spinal
analgesia, and there was no shock at all ; indeed, an hour after
the operation his pulse was only ioo°, whereas in the ward before
he went up to theatre it had been 120° for more than twenty-four
hours. The anaesthesia was perfect, and there was not the slightest
nausea or headache after it. In cases in which the lungs or kidneys
are not in a fit condition for general anaesthesia, spinal anaesthesia
has also a distinct advantage.
Spinal anaesthesia above the lunbilicus seems uncertain, but
some surgeons have done operations on the upper abdomen
with it, though others regard the anaesthetisation of this area as
too uncertain. This is certainly a considerable disadvantage in
abdominal surgery, for owing to uncertainty in diagnosis we may
iind we have to extend an incision begun for disease supposed to
be in the lower abdomen into the upper, or the disease, though
largely in the lower abdomen, may extend into the upper. For
instance, what is diagnosed as acute appendicitis may turn out
to be a perforating duodenal ulcer. Another disadvantage of
spinal anaesthesia for some abdominal operations would be the
inability to employ the Trendelenburg position, at any rate early
in the operation. Speaking of their experience of spinal anaes-
thesia at the German Surgical Congress in 1905, both Bier and
"Silbermark did not recommend it at all for abdominal operations ;
but other surgeons have had a satisfactory experience of it in the
lower abdomen.
There does not seem, then, any reason why spinal anaesthesia
should replace general anaesthesia, except in cases in which the
patient would prefer it, or in which there is so much collapse that
we dread to give a general anaesthesia, and local anaesthesia would
not be satisfactory, and in cases in which we specially fear severe
shock, even though the patient is not collapsed ; also when the
heart, lungs, or kidneys are not in a condition for general anaes-
thesia. We must remember that if there is great abdominal
distension it would not be easy to get the spine well curved
forwards to make the lumbar puncture, and we must also realise
fully that our time for performing the operation under spinal
anaesthesia averages about an hour, though it may be increased
by the addition of adrenalin to the fluid injected.
The technique of this method is fully described in Mr. Barker's
paper.
C. A. Morton.
12
^OL. XXV. No, 96. ^ T
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OBSTETRICS.
The prevention and treatment of post-partum hemorrhage is-
a subject of never-failing interest to the practitioner, and in view
of the sudden and frequently fatal catastrophe which may ensue
as the result of its occurrence, every attempt to suggest new or
improved methods for either its prevention or cure demands
careful examination.
Stanmore Bishop/ as the result of an article on this subject,
has been the cause of a considerable correspondence. In his
original article he produces many arguments for the employment
of a method certainly not new, and sufl&ciently well known,
although not widely taught or practised as a primary method
of dealing with this complication, namely compression of th3
abdominal aorta.
He gives a resum^ of the different causes of post-partum hemor-
rhage as generally taught, under the following headings, namely
primary external atonic, primary concealed atonic, secondary
external traumatic and secondary concealed traumatic, and states
that while the attendant is endeavouring to satisfy himself under
which of these heads the particular case falls, the patient is being
rapidly exhausted by bleeding.
He also states that in addition to the delay while the exact
cause is being mentally decided on, a prolonged search for tears
of the viscera, uterus or vagina is necessary, which has to be
carried out in the midst of a torrent of blood, the clots from
which obscure everything, and only after this exploration can
anyone feel certain that the cause is not traumatic ; and alP
through this tedious and difficult exploration the patient's vitality
is rapidly becoming less.
Next, he states the student is taught that there are fourteen
distinct causes of atonic post-partum hemorrhage, the first of
these being improper management of the third stage, and
describes the student as often exciting irregular and ineffectual'
uterus contractions by squeezing the uterus during its intervals
of partial relaxation, and then removing the placenta by the
hand introduced into the vagina or uterus.
After giving a list of the fourteen causes of atonic post-
partum hemorrhage, he proceeds to eliminate a large number,,
such as haemophilia, which is, as he states, rare, inversion of
the uterus, which does not occur if the third stage is properly
managed, and adherent or retained placenta, as regards which
he considers that any attempt at removal whilst bleeding is going
on is to court disaster, since it is certain to be attempted with
unsterilised hands, while the presence of the placenta in the
uterus makes no difference to the really effective measures which
will arrest the bleeding.
^ Practitioner, 1906, Ixxvii. 145.
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OBSTETRICS. 163
He groups all the remaining causes under the heading of
*' tired uterus," and points out that it is useless to attempt to
stimulate contraction in a uterus that is relaxed, because it is
" tired," and so has lost temporarily the power of contraction.
He makes much of the difficulty of explaining what is meant
by uterine " retraction." The difficulties of explanation are not
great, and, after all, quibbling over the precise explanation of a
term is not of any great assistance to the seeker after truth.
He denies unhesitatingly that uterine contraction — to the
securing which all the energies of the attendant should be
directed — ^is the thing which should be aimed at, and states that
the truth is exactly the opposite. " We must not look to uterine
contraction to stop the hemorrhage, but to cessation of the
hemorrhage in order to permit once more of contraction of the
uterus."
He then states that there are six various measures given by
writers on midwifery by means of which uterine contraction
may be brought about, and asks, " Do the advisers of these
various measures believe in any one of them ? No. We are to
' try ' them all, one after the other, and no one for any length of
time." They are expected to fail, as to each one is appended
the phrase, " If this fail." All having been tried, thrombosis,
produced by the action of perchloride of iron or other styptic, is
the last resource. Finally, having proved the uselessness of all
the measures advised, he draws the attention of readers to the
fact that hemorrhage from veins can be stopped by elevating
the bleeding part, and from arteries hy compressing their parent
trunks, and that consequently elevation of the pelvis will stop
such uterine hemorrhage as comes from uterine veins, and
pressure on the aorta such as comes from uterine arteries.
He, in consequence, advocates the raising of the foot- of the
bed by pushing a table beneath it, or placing the feet of the bed
on two chairs, in order to cope with the venous, and compressing
the aorta in order to stop the arterial hemorrhage.
Having in this way checked the immediate outflow of blood,
the uterus, directly it shows signs of returning vitality, is assisted
to expel contained clots, and the compression of the aorta
handed over to the nurse, while the surgeon proceeds to sterilise
his hands for the purpose of removing adherent placenta, or
searching for lacerations.
He argues that the circulation through the ovarian arteries
not being cut off is sufficient to preserve the contractility of the
uterus, and keep it sufficiently supplied with blood to ensure its
muscular fibre retaining its vitality. He gives, in support of his
contention, the instance of a thigh cut off by a circular saw, and
asks, *' Would the surgeon in such a case, supposing his usual
appliances absent, squirt hot water at the stump or apply
perchloride of iron " ?
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164 PROGRESS OF THE MEDICAL SCIENCES.
He insists that a combination of the two methods he suggests,
namely elevation of the pelvis and compression of the aorta,
are the only true ways of combating post-partum hemorrhage,
and that these two methods in combination must be persisted in,
the latter for three hours if necessary, and the former for twelve.
Gordon Fitzgerald^ protests against the condemnation of
well-tried methods on the experience of one man, and against
that of many others who have proved the efficiency of the
methods they advocate when properly applied. He dissents from
Mr. Stanmore Bishop's description of a typical case of such
hemorrhage as occurring in a healthy young primipara, who has
had satisfactory first and second stages of her labour, and dies
of acute primary atonic post-partum hemorrhage, primary inertia.
He states that the forces which naturally control post-partum
hemorrhage are contraction, retraction, and clotting.
He points out that neither active contraction nor clotting will
permanently check post-partum hemorrhage in the absence of
retraction, which he describes as that plastic force which moulds
the uterus to its contents. He admits that retraction is aided
by contraction, but he has as yet seen no convincing proof that
it is dependent on contraction, and cannot come into action in
its absence.
He allows that compression of the aorta will cause the cessa-
tion of post-partum hemorrhage, but considers that it is difficult
to carry out effectively, except in hospital practice, where there
are numerous assistants. He doubts the influence of elevation
of the pelvis on hemorrhage coming from the veins, especially if
the aorta is compressed. He relies mainly on prophylaxis,
advising that haemophilia, if it be present — and it is well known,
that it is a very rare condition in the female — be combated in
advance by the administration of arsenic, strychnine and chloride
of calcium.
Protraction of the first and second stages is to be avoided,
and the third stage as prolonged as is consistent with the safety
of the patient. All preparations for the treatment of post-partum
hemorrhage should be made in advance.
Prolongation of the second stage should be avoided by the
early use of forceps, but prolongation of the first stage is com-
paratively unimportant.
The indications for termination of the second stage Will be
found in the conditions of the patient's pulse and temperature
In cases of hydramnios and over-distension from twins, especially
in multiparas, the emptying of the uterus should be gradual, and
plenty of time allowed in the second stage ; by early puncture
of the membranes high up in the first condition, and allowing of
considerable delay between the birth of tlie two children in the
second, so that the over-distended uterus, whose contractions are
"^ Practitioner, 1906, Ixxvii, 652.
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OBSTETRICS. 165
sure to be weak at first, may gather strength for its final efforts.
In the case of multiparae, a previous history of adherent placenta
will prepare us for dealing with that condition.
He advises after thirty minutes waiting, if the slight hemor-
rhage which occurs with each contraction due to the expulsion
of already efifused blood does not diminish, the extraction of the
placenta with the gloved hand.
The improper management ot the third stage is the great
predisposing cause.
The immediate grasping of the uterus and expulsion of the
placenta directly after the birth of the child is one of the most
fertile causes. Unless there is undue hemorrhage, no efforts at
expulsion should be practised unless the placenta is found to be
in the vagina. That it is in the vagina can, be recognised by
drawing out all the loops of cord in the vagina, and then grasping
the uterus and lifting it towards the ensiform cartilage, when, if
the placenta is still in the uterus, the cord will be drawn back into
the vagina.
Forcible and rapid attempts at expulsion result in irregular
contractions, possibly imprisonment of the placenta in the uterus
by hour-glass contraction, or detachment of portions of its
maternal surface.
E. Hastings Tweedy^ considers that Stanmore Bishop's state-
ment that *' post-partum hemorrhage is essentially a general
practitioner's tragedy, and that from his own experience and
that of others, cases do not occur in hospital," is unwarranted. He
finds that the statistics of the Rotunda show that in 5,695 women
there occurred fifty-six cases of post-partum hemorrhage, of which
thirty-one were due to retained placenta, membranes, or clots
mechanically preventing the closing down of. the uterus, three
were traumatic, and four of the secondary variety. Of the fifty-
six cases, three died from supervening shock.
Compression of the abdominal aorta as a means of controlling
hemorrhage has been taught and practised at the Rotunda for
years, and is looked upon as a valuable temporary expedient.^
That retraction is independent of contraction is shown by the
following arguments. The uterus does not commonly contract
for about seven minutes after the birth of the child. If the pre-
vention of hemorrhage depended on contraction alone, free
flooding should occur in all cases, and recur after contraction has
passed off.
In the case of a woman delivered with forceps, in the absence
of contraction she must inevitably bleed to death. This we know
does not happen.
During Caesarian section the gradual thickening of the utenne
wall can be seen to be taking place, and that in the absence of
contraction.
^ Practitioner, 1907, IxxviiJ. 361. * Vide p. 121.
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l66 PROGRESS OF THE MEDICAL SCIENCES.
Slight mechanical causes, such as a piece of retained placenta
or a full bladder, appear to be able to prevent retraction, and so
promote the occurrence of hemorrhage.
G. E. Herman,* in continuing previous articles on this subject,
points out that Stanmore Bishop, in his arguments against the
use of perchloride of iron or other astringents in the treatment of
post-partum hemorrhage, is attempting to controvert a proposition
put forward by no modem teacher, and states that this method
is now extinct. It is a bad method because (i) it is unreliable,
and (2) leaves the uterus full of clot, and thus predisposes to
sapraemia. He says that no student is taught to ascertain under
which of four heads the cause of the hemorrhage falls, and that
any student under examination stating that he would search for
lacerations with, presumably, speculum, light, and swabs, as his
first treatment of post-partum hemorrhage, would be looked
upon as a danger to the pubhc, and referred.
Herman refers ^ to the danger of undue haste in securing the
termination of the third stage, and says that this arises not from
producing " spasmodic and inefficient contraction," as claimed
by Bishop, but from the possibility of the membranes not being
detached naturally when the expulsion of the placenta takes place,
and consequently a piece of chorion being left behind.
Herman does not believe in the numerous causes of post-
partum hemorrhage described by Bishop, and states that many
of them may be neglected as not being in any way concerned,
and knows of no evidence that either drugs or diet during preg-
nancy have any effect on the amount of bleeding during the third
stage of labour.
Herman differs absolutely from Bishop in holding that the
current teaching that it is uterine contraction which stops post-
partum hemorrhage is correct.
Pressure is only a temporary means of suspending bleeding
until the uterus has regained its contractile power.
As regards retraction, Herman reaffirms the definitions of
retraction and contraction practically in the terms generally
familiar and almost identical with those used by Fitzgerald, and
he states that one great cause of post-partum hemorrhage is the
empt5^ng of the uterus in the absence of a pain.
He defines a ** tired *' uterus as one that is not contracting
vigorously, and consequently not doing any harm either to the
maternal or foetal soft parts, and considers that the remedy for this
is rest secured by a dose of opium. If, as in the practice of the
most experienced accoucheurs, post-partum hemorrhage is caused
by the retention of a succenturiate placenta, or piece of membrane
in the uterus, the best treatment is to remove it.
He doubts the statement that serious post-postum hemorrhage
is caused by cervical lacerations.
^ Practitioner, 1907, Ixxviii. 445. ^ Loc. cit.
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OBSTETRICS. 167
He agrees with Bishop that when with post-partum hemorrhage
•contraction is absent, pressure is the best thing in the shape of
t)imanual compression appHed to the body of the uterus.
He points out that compression of the aorta in post-partum
hemorrhage was advocated by Baudelocque in 1835, and pre-
viously by Ramsbotham. Robert Barnes and many other
English authors have also recommended it.
In referring to Bishop's suggestion as to the mental state of a
surgeon who would squirt hot water at a divided limb to check
bleeding, he points out that hot water has a specific contractile
•effect on the uterus, so that the cases are in no sense parallel.
The objection to an immediate attempt to replace an inverted
uterus or remove a piece of placenta, that it is likely to be done
with unsterilised hands, is answered by pointing out that if the
attendant has done his duty during the second stage, his hands
-should be sterile, and ready during the third stage for any such
-emergency.
He objects to the statement that a number of " experiments
are to be made ** ; the measures described are not experiments,
but manipulations, each with a definite and necessary object, the
final aim being to secure an empty, clean and contracting uterus,
with retraction in the intervals between contractions. If contrac-
tion cannot be got, pressure must be resorted to. This is best
appHed to the uterus, but there is no reason why the doctor should
not compress the uterus and the nurse the aorta. Lastly, the
great prophylactic is, ** Do not deliver when the uterus is tired."
This series of articles, in the writer's opinion, confuses the
issues. The writers all seem to have some different condition in
mind.
Stanmore Bishop, in his advocacy of what is undoubtedly a
useful method as an adjunct in severe cases, spoils his case by
unnecessary declamation and abuse of an opposition which does
not exist.
To suppose that it is necessary to make a prolonged search for
lacerations in a case of post-partum hemorrhage is ridiculous. In
the first place, as Herman states, hemorrhage from a lacerated
cervix is only quite exceptionally severe, and occurs with a hard,
contracted uterus, which must be obvious to anyone attending a
confinement who observes the condition of the uterus by keeping
his hand on it for a reasonable time, not less than half an hour,
after the completion of the third stage.
In the second place, if the uterus is watched by the hand on
it after the third stage is completed for this period, how often
^does severe post-partum hemorrhage occur ? In the writer's
experience, out of close on 8,000 cases, he has met with himself,
'Or been smnmoned to, only twelve cases, in all of which but two
the hemorrhage was stopped by grasping the fundus through the
•abdominal waU ; in these two sudden severe hemorrhage occurred
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l68 REVIEWS OF BOOKS.
which was stopped by introducing the hand into the uterus and
compressing, the placental site against the closed fist.
Hemorrhage does not occur even in an inactive uterus so long
as the placenta is not detached, and anyone who has done a
Caesarian section knows how firm this attachment is.
Again, in a Caesarian section, when delivery has been effected
in the absence of labour pains, the uterus retracts almost at once
after the delivery of the child, and no hemorrhage occurs except
from the cut surface, and this ceases directly contraction takes
place.
The first method, and the most generally successful one in
ordinary cases, is compression of the uterus. Compression of the
aorta is a useful adjunct. Elevation of the pelvis, though a most
useful proceeding in the treatment of the shock which sometimes
succeeds even a slight hemorrhage, is rather a waste of valuable
time if compression is omitted. Hot water injection is a valuable
stimulant to uterine contraction, but cannot stop hemorrhage in
any other way than this, and in addition helps to clear the uterus
of clot, etc.
The resort to forceps as soon as signs of exhaustion come on
(not because pains are absent), and the management of the third
stage without hurry, allowing plenty of time (up to an hour and
a half if necessary) for the placenta to be separated naturally
while the hand on the fundus guards against ^nd serves as
a warning of relaxation, are the measures which are the best
means of preventing it.
Ergotin and strychnine, the former in small doses, adminis-
tered during the last fortnight of pregnancy have been, in the-
writer's experience, associated with absence of post-partum
hemorrhage in cases where it was anticipated, but this, of course,,
may have been a mere coincidence.
Walter C. Swayne.
IRcvicws of Boohs*
Text-Book of Anatomy. Edited by D. J. Cunningham, M.D.
Second Edition. Pp. xxxiii., 1388. Edinburgh : Young
J. Pentland. 1906.
This a formidable work, larger much than its apparent bulk
indicates, and perhaps too large for the average student.
As far as possible it has been written by various anatomists
trained in the Edinburgh School, so that it may well be termed
the Edinburgh Text-Book of Anatomy.
Digitized by VjOOQIC
.REVIEWS OF BOOKS. l69>
In this second edition many improvements have been made,
especially in the illustrations, which may now rank with the
finest in any text-book.
Additions and corrections have been made in nearly every
section. In the section on *' Osteology/' written by Professor
Arthur Thomson, one notices many additions, and we would like
to suggest many more, as well as corrections. We have referred
in the review of another work to the unsatisfactory account of the
chondro-cranium, and all that has been said there may be said with
greater emphasis here, for by now the works of Froriep, Jacobi,
Levi, and others have established beyond all question the real
facts of the development of the chondro-cranium, and shown that
it very materially differs from the account originally given by
Wiedersheim. The account, too, of the chorda dorsalis must
undergo revision, more especially with regard to its relation to the
basilar plate. The account of the ossification of the skull bones,
is very largely based on the observations of Rambaus and Renault.
Many of these have not stood the test of time, and, as a conse-
quence, accounts based on them will require revision. The
systematic description of the bones is, on the whole, very satis-
factory, although we think much more might have been made of
the distinguishing features of certain of the vertebrae and ribs,
with a view to enabling the student to identify them.
The section on joints is satisfactory, if not particularly interest-
ing ; there is little fault to be found with that on the muscular
system, by Paterson ; but we certainly question the accuracy of
the markings of muscular attachments to the coronoid process,
as figured on page 243, and the insertion of the supinator brevis
is represented as a continuous area on the radius, which is well
known not to be the case. However, these are small points. As
to the section on the ** Peripheral Nervous System," it may at
once be declared to be one of the best in the book, not only from
its accuracy, but from its interest.
As might be expected, the " Central Nervous System " receives
authoritative treatment at the hands of the Editor, who has been
careful to profusely illustrate it with a series of drawings of trans-
verse sections of the brain stem of surpassing excellence. We
know of none which equal them. Great care has been taken to
keep the matter up to date, and we are glad to see due prominence
given to the valuable work of Elliot Smith, as well as that of
Flechsig and Bruce. The student has certainly enough food for
reflection in this section.
The articles on the *' Organs of Special Sense " are exhaustive,
and have, perhaps, a savour of Pestut about them. We regret to
see Jacobson's cartilages illustrated by a drawing of a section of
the nose of a kitten, for the conditions in the kitten and man are
vastly different. It has long formed a subject of discussion, this
peculiar position of the Jacobsonian organ in man. Both in the
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170 REVIEWS OF BOOKS.
textual description of the Jacobsonian organ, and in the chapter
on " Embryology/* this body is described as having a close rela-
tion to the Jacobsonian cartilage, whereas no such close relation
exists, as may be seen in any coronal section of the human nose
up to the third month.
It would be difficult to speak too highly of the chapter on
*' Embryology." It is admirably written and illustrated. Here
and there a point or two might have been clearer, and the
erroneous statements with reference to the Jacobsonian organ
have already been alluded to. Fig. II. on page 41 is not credited
to any animal, but certainly does not belong to man.
Birmingham's account of the digestive system remains much
as he left it, and is an extremely accurate and interesting
•expo3ition of the '* formalin " body.
The article on the ** Lj^nphatics " has undergone a thorough
revision, and has benefited materially by the publication of the
rgreat French work, Poirier et Charpy.
The book is completed by a section on '* Surgical Anatomy,"
written by Stiles. This is a very satisfactory article. It brings
into prominence Chiene's method of locating the various fissures
and convolutions of the outer aspect of the hemisphere.
There will be found in the description of the prostate a curious
contradiction of the description given by Dixon of the " capsule "
of the prostate. Contradiction of this kind are almost inevitable
in a book of this nature and magnitude, but this, we believe, is
the only one in the book, which says much for the careful editing
it has undergone.
It is not an easy task to '* place " this book. Honestly, one
hesitates to recommend it to the ordinary student ; to the
University student, or the student working for the '* Fellowship "
•examination it ought to be essential, and as a guide to the re-
searcher it is sufficiently stimulating. Its value to the last-
mentioned would be greatly enhanced by a bibliography appended
to each chapter.
'Gallstones and Diseases of the Bile-Ducts. By J. Bland-Sutton,
F.R.C.S. Pp. vi., 233. London : James Nisbet & Co.,
Limited. 1907.
The book consists of a series of lectures delivered at the
3Iiddlesex Hospital. The various subjects are treated in a
comparatively brief but lucid manner, and the work is not meant
to compete with the larger monographs on these diseases.
It is a useful compendium for the student and practitioner
rather than the operating surgeon. The indications for treatment
are on orthodox lines, but the author holds strong views on. the
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REVIEWS OF BOOKS. 171
desirability of performing cholecystectomy as a routine measure.
This again is in accordance with the views of many surgeons, but
there are arguments against, as well as for, this procedure.
Because gallstones are recognised as a predisposing cause of
cancer we are told that " it behoves surgeons when removing
gallstones to excise the gall bladder ; " but logically the removal
of the stones is surely the essential need, and the desirability (if
it exists) of performing cholecystectomy rests on other grounds.
There are some good illustrations and a few references at the
•end of the chapters.
•Collected Papers on Circulation and Respiration. By Sir Lauder
Brunton, M.D. First Series. Experimental. Pp. xiii.,
696. London : Macmillan & Co.. Limited. 1906.
There is no need for us to draw attention to the very valuable
experimental work which has been carried out by Sir Lauder
Brunton on problems connected with circulation and respiration.
In this volimie is collected a series of papers which was published
by him between 1867 and 1883. These papers are exceedingly
interesting, and there will doubtless be many who will be glad to
have them all in one volume.
Applied Bacteriology. By Cresacre G. Moor, M.A., F.I.C.,
^ith tlie co-operation of R. T. Hewlett, M.D., D.P.H. Third
Edition. Pp. 475. London : Bailliere, Tindall & Cox. 1906. —
The sub-title of this work — An Elementary Handbook for the Use of
Students of Hygiene, Medical Officers of Health, and A «a/ys^s— indicates
its scope. Its usefulness is demonstrated by the appearance of
the Third Edition. The subject-matter has been brought well
up to date, and the ground covered is sufficient for ordinary
<:lass work. In addition to micro-organisms, ferments are
•considered. There are chapters also on ** Disinfection and
Disinfectants " and on " Water, Air, &c." The illustrations
are a little crude, and the thick paper makes the book incon-
veniently bulky.
Lectures on Midwifery for Midwives. By A. B. Calder, M B,
Pp. xi., 274. London : Bailliere, Tindall & Cox. 1906. — These
lectures given in rather discursive style read very well, and most
of the points required for a midwife are clearly indicated. In
some of the chapters, especially those on mechanisms, it might
have been easier to grasp the subject if it had been tabulated.
It is always difficult to follow a description, even when in good
English, which runs easily from one stage to another without
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172 REVIEWS OF BOOKS.
definitely marking off the other. The chapter oti the child
and its feeding is good and rational. A very useful lecture
would have been one on those cases in which it is advisable to-
send for a doctor, this being one of the most important points
in which to instruct the midwife. The application of the
• Midwives' Act is clearly set out, and should be useful. Auscul-
tation is to be practised only by the ear, in many cases a woodea
stethoscope is much more valuable. The plates, although small
and crowded, are on the whole very useful. We think the book
will certainly find a well-merited sale.
Transactions of the American Pediatric Society. Vol. XVII.
New York : E. B. Treat and Co. 1906. — There is good
scientific work exhibited in this volume. Congenital laryngeal
stridor is shown to be due to a folded gutter-like epiglottis,
which leaves merely a chink for breathing; this condition is-
always present to some extent in young children, and when
excessive stridor appears it must not be confused with
** thymic asthma.*' Very early gastro-enterostomy is favoured
for congenital pyloric stenosis. Citrate of soda, three grains
to the ounce of milk, is very ijseful in intestinal dyspepsia-
Intubation for diphtheria should be performed earlier than is
usual. Cortical decapsulation of the kidneys for severe chronic
nephritis shows better results in children than adults. Milky
pleural effusions, when not due to chyle or degenerated fat, are
caused by altered albumins and globulins. Several of the
other papers are worth reading.
A Preliminary Inquiry concerning the Milk Supply of Schools..
By C. E. Shelly, M.D. Pp. 11. London: J. & A. Churchill.
1906. — This is a report on an inquiry, inaugurated by the
Medical Officers of Schools Association, with a view to-
determining what statistical evidence existed either for or
against the practice of boiling or sterilising the milk supplied
to schools. In response to a circular forty-three replies were
received, of which forty-one have been tabulated. The
figures obtained are curious, but although the returns include
observations on a large number of children, the figures are
not really sufficient ifor the purpose for which they were
collected.' If any lesson is to be learnt, it is that we should
look rather towards the securing of a pure milk supply for
protection against epidemic disease than attempt to guard
agamst infection by boiling or otherwise treating the milk.
The figures are^ handled dexterously but with much- caution,
by the author, and the pamphlet will be found to be interesting
and suggestive to those concerned in the feeding of children*
at boarding schools.
A Manual of Diseases of the Eye. By Charles H. May,.
M.D., and Claud Worth. Pp. viii., 400. London: Bailliere,
Tindall & Cox. 1906. — This is an excellent text-book for the
medical student ; it covers the ground well, and is short and
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REVIEWS OF BOOKS. 173
concise. The statements contained are given in a crisp
manner, and so are likely to remain in the mind of the reader,
but on this account the perusal of the book is rather hke
reading a dictionary; still, also like a dictionary, it is full of
information, and can be confidently recommended to the
student or practitioner who is in a hurry for his knowledge.
A Handbook of Diseases of the Nose and Pharynx. By
James B. Ball, M.D. Fifth Edition. Pp. xii., 388. London :
Bailliere, Tindall & Cox. 1906. — A text-book which has rapidly
run through four editions obviously has proved acceptable to
students and practitioners, and it becomes all the more essential
that the work should be accurate and up to date. The author
has evidently spared no pains to make the many alterations
and corrections that so soon become necessary in a relatively
young and developing speciality, and yet without materially
adding to the size of the book, which is worthy of the author's
reputation.
Davos as Health Eesort. Davos : Davos Printing Company,
Ltd. 1906. — This book of 316 pages, forwarded to us by the
Davos Public Interests Association, consists of a series of
articles written by the best authorities in Davos, and with an
introduction written by Dr. W. R. Huggard, H.B.M. Consul.
The contributors, sprung from many different lands in Europe,
have made Davos their more or less permanent home, and
have acted in friendly co-operation in producing a book which
gives the best information, historical, topographical, geological,
ethnological, botanical, climatic, physiological, pathological
and sociological, of a place which is of profound interest to
those who have visited it, and will be of interest to those who
read about it. Dr. Huggard commends the volume to his
brethren at home, and trusts that they will find it as interesting
as they will assuredly find the place when they make its
acquaintance for themselves.
The Climate of Lisbon, Mont Estoril and Cintra. By Dr.
D. G. Dalgado. Pp. viii., 50. London: H. K. Lewis. 1906.
— This paper is an echo of the Fifteenth International Congress,
held at Lisbon in April, 1906. It is in praise of two health
resorts, and its object is to show: (i) That the climate of
Lisbon in winter is not variable ; (2) that Mont Estoril, as a
winter health resort, is in many respects superior to Biarritz,
Nice and Catania; and (3) that Cintra, "the most blessed
spot in the habitable globe," of Southey, is a very desirable
and charming health resort in summer, but not in winter.
Those of us who visited Mont Estoril last spring can well
realise that the Riviera of Portugal deserves fully to make a
reputation for itself as a climatic health resort. Its salubrity
has been known for ages, for the monks, excellent judges of a
genial climate and of good cheer, selected Estoril and Cascaes
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174 REVIEWS OF BOOKS.
for their monasteries. It is now a very popular sea-bathing^
summer resort, but endeavours are being made to extend its
popularity through the winter also.
The Philippine Journal of Science. Edited by Paul C.
Freer, M.D., Ph.D. Manila. 1906. — We have received
Part VI. of this new journal, published by the Bureau of
Science of the Government of the Philippine Islands. The
inhabitants of these islands may be congratulated on the fact
that they are able to produce such an excellent periodical,,
which must at once take a very high position amongst
the scientific journals of the world. This may be accepted
as the best evidence of good government, and one of the results-
arising from the good influence of the United States in their
eastern colonies. The article on rinderpest, from the serum
laboratory of the Bureau of Science, shows that the Govern-
ment is using every effort to eradicate the disease. Those
which follow, on geological and botanical topics, are illustrated
by means of an excellent series of photographic plates. It will
be difficult to maintain the standard of this and many other
of the publications of the Bureau of Government Laboratories
of Manila.
On Physical Training in Schools, by W. P. Herringham,.
M.D., and The Influence on National Life of Military Training in
Schools, by T. C. Horsfall. Pp. 12. London : J. and A.
Churchill. 1906. — These essays are issued by the medical
officers of Schools Association, and give very terse and useful
evidence in support of the views of the National League for
physical education and improvement. Dr. Herringham remarks
that all boys and girls ought to go through systematic physical
drill, and ought to be taught that it is their proper ambition to
develop their bodies and to be as well grown and strong as they
can. He quotes Almond, who used to speak of it as a religious
duty, and of loafing and bad hygiene as physical sin. Mr.
Horsfall is convinced "that very great good would come to-
English children and to the whole community from the
introduction of military drill and instruction in shooting into all
our schools, and that there would be no drawbacks to the
advantages which it would give in improvement of health,
increase of public spirit and patriotism, and of increase also of
the safety of the nation."
Sonnd and Ehythm. By W. Edmunds. Pp. 96. London:
Bailliere, Tindall and Cox. — Children in primary schools being
taught singing, the author has written this little book to suggest
that it would be to their advantage to be also taught the
mechanism of sound and hearing. The book is written as
clearly and simply as possible; still we cannot help thinking
that much of it, and specially the chapter on musical scales^
would be beyond the comprehension of, at any rate, young
children. The first two chapters deal with the production and
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REVIEWS OF BOOKS- 1 75
conduction of sound and with the wave form of sound vibration.
The third chapter treats of musical scales and intervals^,
harmonies, consonance, dissonance, and beat tones, &c. ; the
fourth with organ pipes and resonance in tubes, and the fifth
with "time" and movement as illustrated by different metre*
in poetry and in dancing. Chapter VI. deals with the anatomy
and physiology of the ear, and connected with it are a series of
models, those of the ossicles much enlarged being quite good;
those of the temporal bone showing inner wall of tympanum,,
and ossicles with drum being quite useless, at any rate for those
unacquainted with its anatomy. The book ends with a short
chapter on the production of the voice and finally a descriptioDi
of the models. The subject of the book is an extremely
interesting one, and we doubt if it would be possible to deal
with it in a more lucid fashion. A number of illustrations add»
considerably to the value of the book.
Supplementary Essays on the Cause and Prevention of Dental
Caries. By J. Sim Wallace, M.D., D.Sc, L.D.S. Pp. vii., 8i..
London : Bailliere, Tindall and Cox. 1906. — This is a book
that every practitioner, medical and dental, should read with
interest. It is very possible that he may not agree with much
that the writer puts so forcibly and quaintly, but the book will
make him think. It is calculated to disturb the complacency
of anyone who imagines he knows all about dental caries.
There is a most healthy want of reverence for generally received
opinions.
A System of Surgical Nursing. By A. N. M'Gregor, M.D.
Pp. xi., 554. Glasgow: David Bryce and Son. [1905.]— This
is a large work of 550 pages. There are a very large number of
works on this subject now to be pbtained, and it is hard to
advise a nurse as to which is the best for them to get. Many
are too much devoted to surgery, but this is quite an exception,
in this particular. Although the main surgical points are
mentioned, there is in each case a fully detailed account of the
nursing aspect. The chapter on dressings and on the prepara-
tion for operation are very good and concise. A few words on
the removal of plaster of Paris would have been of advantage,
as it is sometimes a very difficult process. It often happens
that a breast has to be emptied of its milk, a proceeding
requiring great care and experience, and it is therefore a pity
that the detail of this proceeding has been omitted. There are
no illustrations, though in a work of this sort we doubt whether
this is a disadvantage. We are rather surprised that no mention
has been made of the detail required in private nursing, in fact
the subject is not mentioned. Undoubtedly the book is a very
valuable one, and we should think is assured of a large sale.
Practical Nursing. By Is la Stewart and Herbert E.
Cuff, M.D. New Edition. Pp. viii., 436. London : William
Blackwood and Sons. 1904. — We have seldom met a book
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T76 REVIEWS OF BOOKS.
which has upheld its title as well as this volume. It is practical
from beginning to end — no mere list of duties strung together,
but an entirely readable accumulation of facts written in ^ood
English and in excellent style. We have no desire to criticise
the subject matter ; it is what it is meant to be, and undoubtedly
-every nurse should read it. There are a few illustrations, and
rather curious ones have been chosen — Buller*s shield and
Leiter's coils, both very seldom used. Perhaps it is for this
reason that they have been selected ; also two figures showing
arteries being compressed in a somewhat awkward manner.
We would advise medical students to look through this work ;
it is intensely interesting reading, and is sure to be appreciated.
Le Livre de la Sage-Femme et de la Garde. By Dr. R. De
Seigneux. Pp. 62. Geneve : Henry Kiindig. 1905. — This is
a short hand-book for midwives published in Geneva, the author
being a privat-docent of the University. It is an excellent sjiort
practical manual, and is the more valuable since the author has
incorporated with it a series of hints on the early symptoms
and treatment of cancer of the uterus. While the instructions
given in it are excellent and practical, we think that it errs on
the side of brevity in one or two important particulars. For
example, we do not think that the treatment of post-partum
hemorrhage is sufficiently dealt with by instructing the mid-
wife to massage the uterus, give ergot, and send for a medical
practitioner. This complication is so dangerous and often so
sudden that the directions for its treatment cannot be too full or
too exhaustive. All possible measures should be described, and
the order in which they are to be applied should be Jaid down.
In a case of this kind the patient's life depends on the prompt
application of the proper remedies by the person on the spot,
and the midwife should not be confined to the measures described,
since, if they should prove ineffectual, medical aid would arrive
too late to save the patient. The hints as to the early symptoms
of cancer of the uterus are most valuable, and cannot be too
widely disseminated. A series of capital forms for case-takmg
are embodied in the book.
Lectures upon the Nursing of Infectious Diseases. By F.
J. WooLLACOTT, M.A., M.D. Pp. vii., 147. London : The
Scientific Press, Limited. 1906. — Most books on nursing are
too apt to be a dissertation on the various diseases with hut
little on the actual nursing. In this work the reverse is the
case. For this reason it is a book of considerable value. True,
the symptoms are stated and a very good account of the disease
is given, but it is concise, and it is followed by nursing instruc-
tions which on every page show that the author has evidently
not only an intimate knowledge of the practical side of the
cases, but also he has been able to collect just those little points
in nursing which it is generally so hard to get out of a book. We
would recommend it highly to nurses and even to medical men.
Digitized by VjOOQIC
E&itorial 'Wotee.
The question as to whether it is or is not
Dual desirable that physicians or surgeons
Hospital should have the option of holding office
Appointments* at more than one hospital has recently
been the subject of discussion in Bristol,
the committee of one of the largest medical charities having
been opposed to the dual appointment of a member of their
staff.
In this city we are perhaps especially fortunate in that our
•great medical charities are watched over and provided for by
laymen who have devoted such an amount of time and money
to the work they have taken in hand, that no one can doubt for
one moment their single-hearted desire for the best interests of
their respective institutions.
In approaching this or any question which concerns a great
hospital, we must bear in mind that these institutions are really
great public trusts, which exist, not for the benefit of medical
' practitioners, but in the first instance for the welfare of the
patients who go to them for treatment, and secondly, for the
advancement and teaching of medicine in all its branches ; but
it is obvious that the latter is in reality one of the essential factors
in promoting the interests of the patients in any hospital.
The honorary staff of the particular hospital in question have
pointed out that it is desirable that members of the staff '' should
be encouraged to practise as pure physicians and surgeons,
because in that case they have more time to devote to hospital
work, and therefore greater opportunities for the attainment of
special knowledge and skill ; and the charge of beds is an addi-
tional inducement to assistant-physicians and surgeons to adopt
this line of practice.*- With this view we entirely agree, and
would further add that we consider that those who hold appoint-
ments in the chief hospitals in a medical centre which desires and
Vol. XXV. No. 96.
Digitized by VjOOQIC
178 EDITORIAL NOTES.
expects a University status, ought to devote themselves to
medicine, surgery, or one of the special branches, and not to
engage in general practice.
It may prove desirable and necessary to lessen the number
of physicians and surgeons at a hospital in order to provide
sufficient scope for their acquiring the necessary experience in a
limited field of practice ; but it is obviously to the best interests,
of any hospital to have a few masters of medical or surgical
practice, rather than a larger number of general practitioners.
To leave it open to any physician or surgeon of a hospital to-
engage in any or every line of practice for gain, but to lay it down
that the only restriction on his freedom is that he may not
devote his spare time to acquiring further experience in his par-^
ticular branch of medicine or surgery, not for gain but for pure
love of, and keenness in, his profession, is surely to ** strain at a.
gnat and swallow a camel."
Nothing redounds more to the credit of a hospital than to find
that its physicians and surgeons are sought after, not only by
the rich patients in the surrounding district, but by the smaller
hospitals for the poor attending them, and we feel that
it is only natural and right that the small hospitals should
desire a " slice off the rich man's cake '* for their own patients'
benefit.
We have not touched on the question from the point of view
of the physicians and surgeons on a hospital staff. But there is.
surely some right on their side to determine how far their liberty
to employ their spare time shall be restricted by the charities they
serve. If it is suggested that by serving more than one hospital
any individual physician or surgeon might be overloading his-
time and energies, the same may be said of a large private
practice, and it would be as reasonable to curtail the time he
occupied in serving his private patients, or even acting in any
public capacity, as to dictate hmits to his services to the poor.
It is quite possible that there is room for improvement in
hospital management, both in our own city and elsewhere,
but any alterations must be carefully guided in the right
direction, and any question that arises approached in an open
Digitized by VjOOQIC
EDITORIAL NOTES. 179
spirit, not by the Governors only, but by the doctors also,
who are partners, not servants. Indeed, it is the reputation and
enthusiasm of individual members of the staff on which the
fame and status of any hospital mainly depends.
We have heard it said that the medical staff gain much from
the prestige of their appointments ; but although here in Bristol,
as elsewhere, it is a privilege to be associated with a great
hospital, any prestige arising therefrom is an asset created and
maintained by medical men, not by the philanthropists to whom
Bristol owes so much for providing the no less, but no more,
essential buildings and necessary funds.
It is not, as some seem to imagine, the hospital which makes
the man, but the man who makes the hospital, although in doing
so he may bring credit to himself. To cite but a single example
from the many names which have made Bristol hospitals renowned,
we may point to Greig Smith, who made our Royal Infirmary known
throughout the civilised world by his surgical work there. Yet
how empty is all this reflected honour, for unless the individual
man, like Greig Smith, gives far more than he takes, a hospital
appointment proves for him of little or no value whatever;
it is only a missed opportunity.
Th^ opening of this new hospital is an
The event which must prove of considerable
Cossham Memorial importance to the district in which it is
Hospital. situated. The site is an ideal one, and
the buildings placed upon it have been
constructed with every possible care to make them as ideal as
the grounds.
Arrangements are being made for fifty-two beds, and it is not
intended that there shall be any out-patients. Every care is to
be taken that the privileges and duties of the local medical men
shall not be infringed. As the hospital is well endowed, there
will be no need for any appeals to the philanthropy of the public ;
there will be no subscribers, and therefore no subscribers' letters
of recommendation. With adequate funds for the purpose, it is
Digitized by VjOOQIC
r80 NOTES ON PREPARATIONS FOR THE SICK.
to be hoped that the services of the working staff shall in time
receive due remuneration.
We give on another page an outline of the history and arrange-
ments of the buildings and the constitution of the medical and
resident staff.
The elevated position of the hospital, its isolation from any
near buildings, its graceful style of architecture (early Georgian),
and its central cupola with illuminated clock and Westminster
chimes, will cause this hospital to become a prominent landmark,
embellishing the whole district.
motes on preparations for tbe Q\c\\.
For any chemical analyses mentioned in the following report
we are indebted to Mr. O. C. M. Davis, B.Sc, A.I.C, of the
University College Laboratory.
The '' British Pharmaceutical Codex : an Imperial Dis-
pensatory." — An ideal pharmacopoeia should satisfy three
different requirements. First, it should contain all the drugs
and chemicals in general use ; secondly, it should contain such
combinations of these as are commonly prescribed by medical
men ; and thirdly, it should serve as a standard for purity of
drugs and chemicals, which will be recognised by those persons
responsible for the sale and preparation of these articles.
In order to in any degree comply with these three requirements
it is obviously necessary that a national pharmacopoeia, such, for
example, as the British Pharmacopoeia, shall confine itself strictly
' to those drugs, chemicals and formulae which are the most uni-
versally recognised and prescribed. It necessarily leaves to other
and non-official formularies a multitude of formulae of all kinds
that, while in frequent use, are not in universal use.
From this arises one of the difficulties of modern prescribing.
A prescriber wishes to order, perhaps, " Spirit Soap.'* He has
been accustomed in his hospital work to order it and get a certain
preparation. If he orders it in a different part of the country he
is never sure of getting the same article unless he can specify the
source of the formulae on the prescription.
There are, of course, a number of excellent formularies in
common use, '* Squire " and " Martindale,*' for example, and
these to some extent meet the difficulty.
Digitized by VjOOQIC
NOTES ON PREPARATIONS FOR THE SICK. l8l
The British Pharmaceutical Society are now preparing a work,
to be ,termed the '* British Pharmaceutical Codex/' which will
shortly be published, which will, it is hoped, meet all requirements.
It will contain, besides drugs and chemicals, formulae for acids,
baths, bougies, cerates, drops, effervescent granules, elixirs,
emulsions, enemas, gargles, gauzes, insufflations, mixtures, paints,
tablets, &c, &c., &c. The galenical portion of the book will
therefore include more preparations than any pharmacopoeia yet
published, and will therefore combine the features of a hospital
pharmacopoeia with those of the B. P.
It is hoped that every medical man will use the book, and
prescribe from it. If he then order *' Elixir — (Codex)," he will
ensure always getting the same preparation dispensed without the
delay entailed b}' the pharmacist having to ring him up before
dispensing the prescription.
The book can now be ordered in advance, at los. 6d. per copy,
from th6 Pharmaceutical Society, or, if desired, through the
pharmacist at the Royal Infirmary. As soon as published, a copy
can be seen at the Dispensary of the latter institution.
Alaxa. — Burroughs, Wellcome & Co., London. — Alaxa is
an aromatic liqueur of cascara sagrada, which presents, in a most
pleasant and acceptable condition, the laxative properties of the
bark, in combination with stomachic and carminative principles.
It is of agreeable flavour, and it exerts a marked tonic effect upon
the bowel ; it assures a normal activity, and renders unnecessary
the use of after-dinner pills or digestive aids.
Alaxa is eminently suitable for use in the treatment of the
constipation of pregtiancy. It regulates the action of the bowel
without producing irritation or griping. Whilst purgatives may
adversely affect the course of pregnancy, the tonic laxative
properties of alaxa maintain the normal bowel action, and prevent
interference with the gravid uterus.
The dose is one to two fluid drachms, as may be required.
" Elixoid " Pine Tar Compound. — Burroughs, Wellcome &
Co., London. — A pleasantly-flavoured fluid preparation, contain-
ing pinol, tar, terpin hydrate, Virginian prune, balsam of Tolu, and
ipecacuanha. This combination is very effective in the treatment
of affections of the respiratory organs, as its active components
are excreted by the lungs, and thus exert a slow, steady and con-
tinuous action. It is believed to allay pulmonary irritation, and
is of special service in chronic bronchitis and bronchorrhcea ; it
also relieves coughs, and may be used in cases in which the pre-
parations of opium are inadvisable. Half to two fluid drachms
may be given three or four times a day after meals.
Digitized by VjOOQIC
1 82 LIBRARY.
Nizin. — Burroughs, Wellcome & Co., London. — ^Under this
name Messrs. Burroughs and Wellcome have introduced the zinc
salt of sulphanilic acid, which is recommended for preparing
antiseptic solutions and injections.
The antiseptic value of the sulphonic acids has been recognised
for many years, and zinc-sulphocarbolate (the zinc salt of phenol-
para-sulphonic acid) was included in the British Pharmacopoeia as
far back as 1885.
Sulphanilic acid (amido-benzene-para-sulphonic acid) differs
from the phenol-sulphonic acids by the substitution of the amido
group (-NH2) for the hydroxyl group (-0H), and this small
difference may cause a very profound change in the pharma-
cological action.
Whether Nizin is superior to zinc-sulphocarbolate or not must
be determined by clinical observations, but we imagine it will
prove equally valuable as an antiseptic, and less liable to cause
irritation. The Soloid (gr. 7) affords a ready means of preparing
fresh solutions for urethral injections and for eye-lotions.
XLbc Xlbrarp of tbe
JSristoI flDe&ico«»(IbirurQicaI Societu*
The following donations have been received since the publication
of the List in March.
May 31st, 1907.
J. Paul Bush, C.M.G. (i) .... . . . . 3 volumes.
L. M. Griffiths (2) 10 „
R. Shingle ton Smith, M.D. (3) -2
William Warren Potter, M.D. (4) 4
SIXTY-FOURTH LIST OF BOOKS.
The titles of books mentioned in previous lists are not repeated.
The figures in brackets refer to the figures after the names of the donors,
and show by whom the volumes were pres^ented. The books to which no
such figures are attached have either been bought from the Library Fund
or received through the Journal.
Adami, J. G. . . Inflammation , 1907
Allbutt and H. D. Rolleston, T. C. A System of Medicine. Vol. II.,
Part 2 1907
Bland-Sutton, J. Gall-Stones and Diseases of the Bile-Ducts . . . . 1907
Buchanan, A. M. Manual of Anatomy. Vol.11 1907
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LIBRARY. 183
^Chlorine, The Disinfectant Value of [n.d.]
CoekSy W. P. . . Treatise on Operative Surgery (2) 1837
CrippSy H. .. On Diseases of the Rectum and Anus .. 3rd Ed. 1907
99 . . Cancer of the Rectum 1907
Crowley, R. H. The Need, Objects, and Method of the Medical In-
spection of Primary Schools 1907
Deanesly, E. . . Modem Methods of Diagnosis in Urinary Surgery 1907
Encyclopedia and Dictionary of Medicine and Surgery, Green's
Vol. IV. [1907]
Feindel, H. Mefge and E. Tics and their Treatment (Trans, and Ed.
by S. A. K. Wilson) 1907
'Ciadd, H. W. .. A Synopsis of the British Pharmacopoeia (1898)
6th Ed'. 1907
'Hare, H. A, . . Text-Book of the Practice of Medicine . . 2nd Ed. 1907
■Herman, G. E. Diseases of Women [3rd Ed.] 1907
„ . . First Lines in Midwifery New Ed. 1907
■Hope, Mrs, . . Memoir of James Hope, M.D. (Ed. by K. Grant)
(2) 2nd Ed, 1843
Xange, F. . . Degeneration in Families (Trans, by C. C. Sonne) 1907
Latham, A. . . Pulmonary Consumption 3rd Ed. 1907
Lettsom, J. C. Hints designed to promote Beneficence, &c. . . (2)
Vols. II., III. 1801
Lister, Lord . . The Third Huxley Lecture (i) 1907
Lloyd, W. . . Hay-Fever, Hay-Asthma 1907
HcKisaek, H. L. A Dictionary of Medical Diagnosis 1907
Jleige and E. Felndel, H, Tics and their Treatment (Trans, and Ed.
by S. A. K. Wilson) 1907
■Tage, F. J. M. Elements of Physics 1907
Palmer, ** The Times " Report of the Trial of William . . . . (2) 1856
'Rabagliatl, A. The Functions of Food in the Body 1907
Hamsay, A. M. Eye Injuries 1907
RoUeston, T. C. Allbutt and H. D. A System of Medicine Vol. IJ.,
Pt. 2 1907
7on Noorden, C. Metabolism and Practical Medicine (Ed. by I.
Walker Hall). Vols. I., II 1907
li^alker, J. W. T. The Renal Function in its Relation to Surgery . . 1907
Wells, J. W. . . The Influence of Cod-liver Oil on Tuberculosis , . 1907
TRANSACTIONS, REPORTS, JOURNALS, &c.
American Association of Obstetricians and Gynecologists, Trans-
actions of the . . (4) Vols. XII., 1900 ; XV. — XVII. 1903 — 1905
American Journal of the Medical Sciences, The . . Vol. CXXXII. 190^
American Medicine N.S., Vol. I. 1906
American Society of Tropical Medicine, Papers of the Vol. II. 1905 — 1907
American Surgical Association, Transactions of the . . Vol. XXIV. 1906
Annales de Dermatologie et de Siphilographie . . . . Tom. VII. 1906
Archives de Neurologie Tom. XXI., XXII. 1906
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184 LIBRARY.
Archives of Pediatrics Vol. XXIII.
Australasian Medical Gazette, The Vol. XXV.
Bookseller, The
Bristol Medico-Chirurgical Journal, The Vol. XXIV.
British Journal of Children's Diseases, The Vol. III.
Briiish Journal of Dermatology, The Vol. XVIII.
Bulletin de I'Academie de Medecine . . . . Tom. LV., LVT.
Bulletin de I'Academie royale de Belgique Tom. XX.
Canadian Practitioner and Review, The Vol. XXXI.
College of Physicians of Philadelphia, Transactions of the
Vol. XXVIII.
Congres (XVn»e.) international de Medecine, 1906 (3) Sect, de Mede-
cine, 2 parts, 1906 ; (i) Chirurgie, 2 parts 1906—
Contributions from the Department of Neurology, Harvard Medical
School Vol.11.
Gazette des Hopitaux de Toulouse
Hospital, The Vol. XL.
Hospital —
Johns Hopkins Hospital Reports . . . . Vols. XIII., XIV.
Indian Medical Gazette Vol. XLI.
Johns Hopkins Hospital Bulletin Vol. XVII.
Journal of Hygiene, The Vol, VI.
Journal of Mental Science, The Vol. LI I.
Journal of Nervous and Mental Disease, The . . Vol. XXXIII.
Journal of Obstetrics and Gynaecology, The Vol. X.
Journal of the American Medical Association, The . . Vol. XLVII.
Journal of the Royal Sanitary Institute Vol. XXVII.
Library, The N.S., Vol. VII.
Lunacy, 3 ist Report of the Commissioners in (2)
Luzerne County Medical Society, Transactions of the Vol. XIV.
Medical Annual, The
Medical Record Vol. LXX.
Montreal Medical Journal. The Vol, XXXIV. j
Miinchener medizinische Wochenschrift Bd. II. fiir
Northumberland and Durham Medical Journal, The
Post-Graduate, The Vol. XXI.
Progressive Medicine Vol. 1.
Revue generale d'Ophtalmologie Tom. XXV.
Rhode Island Medical Society, Transactions of the Vol. VII., Pt. 3
Smithsonian Report for 1905 /.
Therapeutic Gazette, The Vol. XXX.
Treatment Vol. X.
Wiener klinische Wochenschrift
Zentralblatt fiir innere Medicin
906-
906
906
906
906
906
906-
906-
904
906'
877
906^
907
906'
905]
906-
906-
906-
907
906
906-
906
906
906
906'
906.
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MEETINGS OF SOCIETIES..
Bristol flDe&ico*CbiruraicaI Societs*
March 13th, 1907.
Mr. James Taylor, President, in the Chair.
The meeting was devoted to the consideration of Cases and'
Specimens illustrating various phases of Syphilis.
Professor Walker Hall and Dr. Carey Coombs demon-
strated Pathological Specimens, macro- and microscopical.
Dr. MiCHELL Clarke showed sections illustrating Syphilitic
Diseases of the Brain and Spinal Cord.
The following cases were shown : — Charcot's DiseaseToffthe
Knee Joints, by Dr. Alexander; Disseminated Choroiditis, by
Dr. Ogilvy ; Relapsing Chancre, Spontaneous Fracture of Tibia,
and Tertiary Periostitis of Radius, by Mr. Hey Groves ; Secondary
Syphilis with Sloughing Tonsil and Suppurating Glands in|the
Neck, Necrosis of the Lower Jaw, Congenital Ulceration ofJNares
and Palate, and Recurrent Gummatous Ulceration of thefScalp,
by Dr. Kenneth Wills.
Patient treated with Intra-muscular Injections of Lactate of
Mercury, and a patient with a Tubercular Syphilide, thejdisease
having been acquired innocently, by Dr. Nixon.
April loih, 1907.
Mr. James Taylor, President, in the Chair.
Mr. C. A. Morton showed a specimen of Large Ovarian Tumour,.
weighing loj lb. and measuring 13 in. by 10 in. by 6 in., which
had been removed from a child of ten years of age. Sections^
showed the tumour was an adeno-sarcoma.
Dr. E. C. Williams showed (i) A boy with Enlarged Liver and
Spleen. The spleen, first noticed about Christmas last, extended
downwards nearly to the iliac crest and forwards to the middle
line. The liver edge could be felt two inches below the costal
margin. There was slight jaundice, slight clubbing of the fingers,
and toes. There was a faint systolic murmur at the heart's apex.
Leucocytosis was distinct, pointing to the presence of an infective-
agent. The disease did not appear to be due to any of the
exanthemata. (2) A case of Sporadic Cretinism in a girl aged
3i years, after six months' treatment with thyroid entract. There-
had been very marked improvement. Nothing abnormal had
L
Digitized by VjOOQIC
l86 MEETINGS OF SOCIETIES.
been noticed in the child until after whooping-cough at four
months of age.
Dr. Edgeworth read notes on a case of Double Conseiousness.
In the dreams of sleep there is no sharp division between per-
ceptions and conceptions, for the latter are projected and have
the character of perceptions ; secondly, in dreams, there is an
•entire absence of logical control ; and thirdly, the emotional side
of mental processes is exaggerated. The condition of hypnosis is
closely related to that of dream-consciousness. Some of the
hypnotised remember the events of the hypnotic state ; others
■entirely forget them on waking. In spontaneous somnambulism
the individual possesses sense-perceptions and translates his
motor ideas into acts. The condition of double personality is
clearly akin to somnambulism, but differs from it in that its
onset is in waking life, and also in its prolonged duration. The
example the speaker described was that of a man who found
himself, he thought, in Old Market Street, Bristol, and asked his
way to the police station, but could not tell his name nor where
he came from, nor how he happened to be in Bristol. He was
brought to the Royal Infirmary. A clue was found through his
shirt markings, and it was discovered that a man had been missing
from the town so discovered. A police officer, armed with this
information, asked the man if he was Mr. of a certain town.
The man said yes, with astonishment. In a little while the man's
memory returned, but he could not recall leaving his. native town,
nor any event since then until coming partly to himself in Old
Market Street. He had been missing from home a month, but
what he had done in that month remains a mystery. There are
many similar cases on record. In one, the man when hypnotised
recollected what he had done during six weeks of aberration, but
could not recollect it unless hypnotised. It is the subconscious
or infra-liminal ideas, thoughts, sensations and perceptions which
form the basis of dream-consciousness, somnambulism, hypnosis
and double personality.
Dr. Walter Swayne read a paper on Cerebral Complications
in Pregnancy and Parturition.
Dr. Carey Coombs read a paper on Rheumatic Carditis in
Childhood.
Dr. Bertram Rogers read notes on a case of Sclerodermia
ivith Trophic Lesions.
J. Lacy Firth.
H. F. Mole, Hon, Sec.
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Xocal nDe^icaI motes-
University College, Bristol. — Examination Results. — ^The
Mowing successes have recently been gained : —
Conjoint Board. — Biology : B. G. Deny, A. G. T. Fisher,
<j. H. Piercy. Anatomy and Physiology : R. C. Clarke, J. F. H.
Morgan. Medicine: J. W. J. Willcox.* Surgery: A. E. lies,
E. J. Dermott, R S. Connellan,* C. E. K. Herapath.* Mid-
wifery : R. G. Vaughan.
L.D.S. — Chemistry and Physics : F. C. Willows. Mechanical
Dentistry and Dental Metallurgy : G. F. Fawn, W. E. Dnimmond,
J. R. Hudleston, P. J. Burton. Final Examination : C. A. J oil.*
Fart II. only : W. H. Ireland.*
L.S.A. — Medicine (Part I.) and Forensic Medicine : J. F.
McQueen.
Appointments. — D. S. Davies, M.D. Lond., has been appointed
Examiner in State Medicine for the University of London.
C. E. K. Herapath, M.R.C.S., L.R.C.P., has been appointed
Casualty Officer at the Bristol Royal Infirmary, Cyril
•C. Lavington, M.B., B.S. Durh., has been appointed Out-Patient
Physician to the Bristol Children's Hospital. Frederick H. Rudge,
M.R.C.S., L.R.C.P., has been appointed House Surgeon to the
Torbay Hospital, Torquay. E. H. E. Stack, M.B., B.C. Cantab.,
P.R.C.S. Eng., has been appointed Honorary Assistant Surgeon
to the Bristol Eye Dispensary.
Bristol General Hospital. — As mentioned in our last issue, a
public appeal has been made for ;fi8,ooo for this institution for
.greatly needed improvements. It is announced that ;£i5,55o
have already been promised, and it is hoped that the remainder
will be obtained shortly.
Royal United Hospital, Bath.— The late Dr. Thomas J. Bennett,
formerly of Tunbridge Wells, has bequeathed the whole of his
■estate, subject to certain legacies, amounting to ;f 20,000 to this
institution. This sum will be devoted to the augmentation of
the permanent endowment of the hospital. This legacy will not
interfere with the efforts of the Mayor of Bath, who is trying
to extinguish the debt of /6,ooo against the hospital.
Royal Mineral Water Hospital, Bath.— At the annual meeting
■of this institution held recently it was stated that 1,185 in-patients
had been admitted during 1906, an increase of 24 compared with
1905. The average daily number of occupied beds was 145. An
^lnfavourable balance of ^^214 on the year's working was reported.
Winsley Sanatorium, Bath. — At a recent meeting of the House
* Completes examination.
Digitized by VjOOQIC
100 LOCAL MEDICAL NOTES.
Committee it was pointed out that certain beds could now be-
allocated to persons residing within the counties of Somerset,
Gloucester and Wilts, on payment of 35s. per week, and persons,
living outside these districts could be admitted for £2 los. weekly,
provided there were vacant beds not required by residents of the
three counties. Application should be made to the Secretary.
Cardiff Infirmary. — In the annual report of this institution an
appeal has been made for ^^30,000 in order to accommodate sixty-
four additional in-patients, bringing the total number of beds up
to 250. The infirmary serves a district comprising a population
approaching half a million, and there are constantly between
500 and 600 patients awaiting admission. A promise of £5,000
has already been received provided the remaining £25,000 are
subscribed within six months.
Royal Devon and Exeter Hospital, Exeter.— At a meeting of
the Governors held recently it was reported that the adverse
balance against the institution amounted to £1,392, being £866
more than last year. The chairman pleaded for more general
support, failing which more funded stock would have to be
sold.
The Workmen's Compensation Act.— An interesting case,
bristling with medical technicalities and details, w^as heard in a
local County Court recently. The applicant was a pork butcher's
assistant, aged 26, who sustained an accident on the 2nd October;
1906, straining himself by lifting a heavy lead-lined pickle-tub.
His statement was that he felt something had gone wrong, and
pain had come in his left shoulder when he got home. He worked
on and did not seek medical advice from his club doctor until five
weeks after the alleged accident, on a day when he asserted
that he fainted while standing at his own fireside doing nothing.
During the long period between the accident and this the pains
grew gradually worse, and in his own words, his heart ** did beat
very hard.*' He was treated for a month in a local hospital, and
there seems to have been some doubt as to the diagnosis. The
disease, however, was designated subclavian aneurysm. Later
on the man brought an action against his master on the grounds
that he had sustained an injury in the course of his employment
which determined the illness.
Ample scope was given during the inquiry at the Court for
the minute discussion of aneurysm in all its bearings. Counsel
for the respondent, with his then knowledge of the subject, would
have little difficulty in satisfying any medical examining board.
Medical witnesses were at the table vis-a-vis, and much interest
was taken in the case. The point originally raised was that the-
applicant had strained an artery under the collar bone. What
was the disease. Was it aneurysm or something of a less grave
nature ?
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LOCAL MEDICAL NOTES. 189
The Ocean Accident Company sent down one of their medical
referees, who with one of the local doctors minutely examined
the applicant. Separately at first, and then together, they con-
cluded that the man had no aneurysmal dilatation whatever.
When the case came on for hearing, the diagnosis suddenly
veered round from the region of the subclavian artery to the arch
of the aorta. Physical signs were adduced — an accentuated
second aortic sound and a loud and distinct murmur conducted
towards the axilla. There was some pulsation above the clavicle,
and the medical witness could feel the artery quite distinctly.
By His Honour the Judge : " And what was your deduction
from this ? "
Answer : ** That the man had strained the arch of the aorta."
Later on, in reply to the Counsel for the respondent : " The
aneurysm was traumatic, not spontaneous."
Another medical man had examined the patient and signed
the disease up as subclavian aneurysm. This was a lever for
further cross-examination.
" Would you agree or disagree with this diagnosis ? " — '* I
should not entirely agree."
" Then you disagree on that ? " — " I do not entirely disagree.
Aneurysms may be of different degrees. I consider it was the
beginning of the dilatation which ultimately leads to serious
aneurysm."
The Judge : " You say there was aneurysm, but it was so
small as not to appreciably make itself apparent ? "
Answer : '* There was no swelling, but there was undoubtedly
slight aneurysm."
By the Counsel : '* Was there or was there not an aneurysm ?
... I cannot accept your answer unless you tell me where
mere dilatation ends and aneurysm begins."
Answer : "I should say in this sense there was an aneurysm."
Further on by the medical witness : ** He is better, he is
comparatively well."
The medical opinions on behalf of the respondent were to the
effect that the man did not suffer from aneurysm, and had no
signs of ever having had such.
The Judge asked whether a small aneurysm in November
might not have disappeared in April.
Answer by one witness : *' It would have been so small that
it could not be diagnosed." Later : '* The first and essential step
in diagnosing an aneurysm is the presence of a tumour or swelling."
On the question of the man's symptoms the Judge cross-
examined one of the medical witnesses :
" Did not the strain of the accident cause all that the medical
witness for the applicant had described — Yes or No ? — palpitation,
for instance, which the man stated he still suffered from six months
after the accident."
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igo LOCAL MEDICAL NOTES.
The Judge seemed very irritated by the medical witness giving
a qualifying answer.
" Would not a bicycle ridden too hard cause palpitation — ^Yes
or No ? "
The character of the man's pain was scarcely that which one
would have expected in an aneurysmal dilatation of the aorta,
as he described it, *' in his left shoulder shooting up to his ear
and down into his heart." The pain was persistent since the
accident six months ago.
The decision arrived at by His Honour was easily anticipated.
He had to determine whether the applicant's illness was due to-
an accident, and if so, what was the cause of the accident, and
whether it arose in the course of the man's employment. He
found that the applicant did meet with an injury from the Hfting
of the pickle-tub, that he was subsequently ill owing to an undue
strain, and he was still suffering from it. Incidentally he remarked
that he had had two doctors before him who formed an opposite
opinion, but he had to consider what was the means of knowledge
they had in forming their opinion. They did not see the man
until a long time after the accident, and therefore it was very
difficult for them to say what was the cause of an illness that
commenced months and months before.
Cossham Memorial Hospital. — The late Mr. Handel Cossham,.
who had represented in Parliament this division of Bristol — the
East — for several years and until his death, left in his will his
residuary estate for the purpose of establishing a hospital. He
had no children, but left a widow, and as he was never considered
a wealthy man, it seems most likely that the charitable institu*
tion that was present to his mind — ^generous and beneficent as
it was — ^would at the most be a fair-sized Cottage Hospital.
Owing to various circumstances the estate got into Chancery,
and this occasioned a considerable delay in the winding-up.
Strange to say, this delay was a fortunate thing, for the Trustees
had to manage the collieries and keep them going, and luckily
they fell upon very good times in the coal trade, which is always
a fluctuating one, and made excellent profits. Not only so, but
the collieries were sold at the top of the financial wave ; and so,
in the end, the grand total of £120,000 was in hand for building
and endowment. The site chosen is at the top of Lodge Hill, in
the parish of Fishponds, but in close proximity to the populous
district of Kingswood ; and with the land around the hospital^
and two well-made private roads, consists of nearly fifty acres.
The ground is high — the highest in the district — and is about
350 feet above sea-level. It commands a most extensive prospect,
and especially from the balcony on the central tower. To the
north are the Cotswolds, about Wotton-under^Edge ; to the east
Kelston and Lansdown hills and the Bath districts ; to the south
the Mendips ; and more westerly Bristol itself ; whilst to the
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LOCAL MEDICAL NOTES. I9I
west are the Severn Valley, the Forest of Dean, and the distant,
hills of Wales.
The neighbourhood is also a historical one. Years ago it
formed part of the king's wood, and almost within a stone's throw
of the hospital is a large round brick tower, which is said to
represent a hunting-tower in the reign of King John. Below
Lodge Hill on the western side runs *' The Causeway," an old
Roman road to Bath.
The building itself is very imposing, being constructed of the
grey stone of the neighbourhood, faced with the best Bath or
Corsham stone. The centre block contains the entrance hall,^
surgeon's and matron's sitting rooms, the reception and board
rooms, the surgery, dispensary, and at the back the kitchens and.
offices. On the western side rises up the tower, already spoken
of. This tower has a copper-covered cupola and an illuminated
clock (four faced, and furnished with the Westminster chimes).
This clock is connected by electric wires with all the time-pieces .
in the establishment, so that everj^here the time is synchronous.
Near this tower, at its base, are the two surgical wards, male and
female, and also the great staircase leading up to the first floor,
where are also two sihiilar wards, the medical male and female.
On the ground floor, to the south of the wards, is the operating
theatre. This is one of the handsomest and the best equipped in
the country. The floor is laid with white square tiles, slightly
toughened on the surface ; the walls are covered with pale green-
coloured tiles, highly vitrified and known as " Brit-Opal," made
and placed by the Adamant Co., Ltd., Birmingham. Above the
cornice line ivhite tiles are used, and carried up into the lantern,
which gives light and assists also in the ventilation of the theatre.
Where the floor level ends the edges are mitred and decorated
with darker tiles, so that here and wherever edges meet, so to
speak, everything is rounded off, leaving no edges anywhere for
dust or germs to rest. All the tiles are embedded in Portland
cement, and secured in place with Birmingham cement. On each
side of the theatre is a large radiator, heated with low-pressure
steam, and guaranteed by the contractors — ^^lessrs. Bradford —
to give a temperature of 75° F. on the coldest winter night.
Behind each radiator is an inlet for cold fresh air. and a contin-
uous circulation of air is maintained by two fans in the ceiling.
Leading into the theatre are two smaller rooms, all constructed
with the same materials, the anaesthetising room and the steril-
ising one. The sanitary' arrangements consist of lavatories,
tanks and ample discharge pipes, which terminate in a deep
glazed channel which runs the length of one side of the
floor.
The water supply consists of pure hot and cold sterilised and
ordinary hot and cold water. The supply is introduced by
means of copper pipes, including the necessary ties and clips, ^
Digitized by VjOOQIC
192 LOCAL MEDICAL NOTES,
i-inch hot and cold water, quarter-turn taps, and wrist-action
taps, sprays and douches.
The four wards are all the same size. They are large and
■spacious, and will furnish ample cubic capacity for the ten adult
beds and two cots which are being placed in each one. The floors
are laid with cement, and covered wi th teak blocks. The patients'
lockers are also of teak, with brass fittings, and the chairs made
of dark-stained wood, all of which will form a good contrast to the
best Lawson-Tait bedsteads in white enamel and the bright-
coloured bedspreads. In the centre of each ward is a stove,
which can be used for extra warming should the radiators along-
side the walls be insufficient in cold weather, and near each stove
a handsome plate-glass covered table, fitted with drawers at each
end.
Leading out of the far end of each ward are lavatories and
w.c/s, furnished with the most approved fittings, and on each
floor is a very commodious ward kitchen and larder. Adjoining
the wards on each floor there is a day room for patients, the one
on the ground floor for females, and the one above for males.
This latter one has a covered open-air space and an open balcony,
where the men may smoke at times. On each floor are bath-
rooms for the patients. At the north end of the building are the
isolation wards. These are separated from the rest of the building
by double doors and an intervening corridor. There are wards
on each floor, with separate offices, and nurses' sitting and sleeping
rooms. Connected with these wards is an out-door spiral stair-
case, which can be used in cases of emergency. The same arrange-
ments exist for the other main wards. •
In the basement are various offices^ but worthy of special
note are a dark room for photography, an X-ray chamber, and
the post-mortem room.
Beyond the main building, westward, is another distinct block,
where are the laundry, engine-room, stable, coach-house, and
mortuary.
As the capabilities of the hospital in every way are beyond
those of the ordinary cottage hospital, the Committee determined
to have an honorary working staff and an honorary consulting
staff commensurate with these surroundings. The honorary
consulting staff is represented by two physicians and two sur-
geons, and these are respectively Dr. Shingleton Smith and
Dr. J. Odery Symes, and Mr. C. A. Morton and Dr. James Swain.
The honorary working staff is Dr. Nixon and Dr. Bertram Rogers
as the physicians, and Dr. E. Hey Groves and Dr. Stack as sur-
geons. Mr. A. L. Flemming has been appointed anaesthetist. The
house surgeon is Dr. G. C. Mort, of the Victoria University,
Manchester, and the matron. Miss Maun, late of the Infirmary,
Gloucester.
Digitized by VjOOQIC
Zbe Bristol
nDebtco^Cbtvuroical JouvnaU
'* Scire est nescire, nisi id me
Scire alius scireC*
SEPTEMBER, I907.
RHEUMATIC CARDITIS IN CHILDHOOD.
Carey Coombs, M.D. Lend.,
Demonstrator of Pathology, University College, Bristol ;
Assistant Physician, Bristol General Hospital,
These remarks are prompted by a survey of four recent autopsies
and sixty-five cases seen during the past few years. For my
pathological notes I am indebted to Dr. Michell Clarke, Dr. Cecil
Williams, and Dr. T. E. Holmes. Of the clinical cases twenty-
four are my own out-patients, and the remainder in-patients at
St. Mary's Hospital and at the Children's Hospital, Bristol, the
notes of which I am able to use by the kindness of those physicians
under whom the children were admitted. The in-patients show
a larger percentage of severe types of carditis than the out-patients,
as one might expect. Of seventy-five children seen in Bristol
with various rheumatic disorders, forty-five, or 60 per cent., had
rheumatic carditis. Forty of the cases are girls, twenty-five boys ;
the boj^ are relatively more liable to the severer forms of rheumatic
heart disease. The age at which the first evidence of rheumatic
H
Vol. XXV. No. 97.
Digitized by VjOOQIC
194 DR- CAREY COOMBS
infection was seen varied from 3J to 14, and averaged 8. In
only six, at the most, did the cardiac symptoms precede other
rheumatic phenomena.
The pathology of rheumatic carditis presents four salient points.
First, it is a carditis ; for example, in my four autopsies the
endocardium and myocardium were inflamed in each instance,
and the pericardium three times. Second, the rheumatic infection
is blood-borne, and attacks the heart just as it would any other
organ, by way of its own special nutritional blood supply, in this
instance the coronary arteries. That this is so is suggested by
the simultaneous invasion of all three layers of the cardiac wall
and by the position of the lesions, periarterial in the muscular and
primarily subendothelial in the serous layers. Further, acute
arteritis and other infective lesions may be met with in the
coronary arteries in rheumatic carditis. In my four cases there
was subendothelial fatty change at the root of the aorta, in the
area fed from the coronary arteries. Third, the gravity of
rheumatic carditis in the earliest or *' childhood " stage Hes
mainly in the damage done to the muscle. This is on a priori
grounds to be expected ; the heart's main functions are muscular,
and the serous layers clothing the myocardium are merely
accessories to the easy and effective performance of those functions.
Both clinically and after death the great feature of acute rheu-
matic carditis is ventricular dilatation, as has been so ably shown
by Dr. Lees and Poynton.^ In later years the permanent serous
lesions become important ; by that time the myocardium shows
little trace either in its histology or in its functional capabilities
of the damage inflicted upon it at the time of the invasion. Fourth,
rheimiatic carditis, like all rheumatic lesions, is remarkably apt
to recur — or should it be said to recrudesce ? Perhaps the infec-
tive agent lies quiet in the cardiac tissues awaiting opportunity
to reassert itself ; perhaps it is stored elsewhere in the body, and
issues thence at intervals to infect the heart again. It is worthy
of remark that in all my four autopsies (and in others I have seen)
1 For larger statistics see Poynton, Med.-Chir, Tr., 1899, Ixxxii. 355.
This paper is referred to later in this article.
^ Med.-Chir, Tr., 1898, Ixxxi. 419.
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ON RHEUMATIC CARDITIS IN CHILDHOOD. I95
the interbronchial lymph-glands were much enlarged. Be this
as it may, certain it is that the recurrences lead to the establish-
ment of permanent fibrosis, eventually more important in the
serous than in the muscular layers ; in the early acute stages,
however, it is the myocarditis that kills.
This way of regarding rheumatic heart disease, that is, as a car-
ditis principally important in childhood by reason of the muscular
lesions, is confirmed by clinical experience. Of my sixty-five
cases, no less than thirty-eight presented certain physical signs
about to be described ; and of the remaining twenty-seven, ten
were of the same kind, but the signs were incompletely developed.
They were like enough to those in the larger group, however, to
make one think them due to the same pathological process
occurring in a less severe degree.
The typical physical signs are as follows. On inspection,
the impulse is seen over an area extending from the left
sternal border, or even from the right of the sternum, to an
inch or more outside the left mammary line, and from the third
left space above to the fifth or sixth left space below. It is usually
possible to see that the impulse is wavelike or peristaltic in
character ; the wave begins at the sternal ends of the third and
fomlh left spaces, and travels downwards and outwards to dis-
appear outside the nipple in the fifth or sixth left space. As
it reaches this latter extreme an apparent sinking-in is noticed
in those spaces where the wave was first seen. This gives an
impression of systolic retraction, yet it is in reality not a retraction
but merely a rebound, the chest- wall falling back into the position
which it occupied before it was thrust forward by the contracting
heart. The point of maximum impulse is at or external to the
left mammary line, usually in the fifth space ; here it is so firm
and well-sustained in the average quiescent case as to prove the
presence of ventricular hypertrophy. At the inner end of the
third left space a sharp diastolic shock is felt, presumably due to an
abrupt forcible closure of the pulmonary valves under the influence
of h)^ertension in the lesser circulation. Sometimes the peri-
stalsis I have described is so vibratile as to give the impression of
a presystolic thrill ; this, however, is never so rough, powerful and
Digitized by VjOOQIC
196 DR. CAREY COOMBS
definite as the thrill of mitral stenosis. I have felt a systolic
thriU at and external to the apex. The deep cardiac dulness is
transversely increased both to right and to left ; it may even
extend from the right mammary line to the left mid-axillary line.
The auscultatory signs at the apex show a certain progress.
The first departure from the normal is a lengthening and blurring
of the first sound ; then a definite systolic bruit develops after
the first sound, which may finally replace it. This is transmitted
into the axilla and, of course, indicates mitral leakage. Next the
apical second sound becomes doubled, and then, but often not till
some time after, a murmur is added to the second half of this
second sound. This, hard to distinguish at first, lengthens and
strengthens till at last it runs into the beginning of the next cycle,
becoming, in fact, a presystolic murmiu*. This is not as rough and
loud as that of mitral obstruction, and it is not due to valvular
disease.
At the base the only noteworthy feature is a tremendous
accentuation of the pulmonic second sound, which is often
doubled also ; the explanation of this accentuation is, of course,
the usual one — ^raised tension in the pulmonary artery.
Now these signs — outward displacement of the apex-beat,
widened area of impulse, abnormally ready perception of the
peristaltic nature of systole, increase of the transverse cardiac
dulness on both sides, the murmur of mitral incompetence, and
the signs of raised pulmonary tension — are all due to a dilatation
of both ventricles. That there is h5^ertrophy is suggested by
thie firm character of the impulse at its maximimi point ; but the
principal feature is dilatation. The ventricles have stretched
because their walls are atonic, and the atony is due to the action
of the rheumatic virus upon the myocardiimi.
From time to time the dilatation, which has been partially
recovered from in the interval, is acutely exaggerated by a fresh
infection of the heart muscle ; not infrequently this is so damag-
ing to the myocardial cells as to lead to a fatal asystole. Post-
mortem, the heart is enlarged transversely and globular, owing to
ventricular dilatation ; the auriculo-ventricular orifices are
stretched, and the ventricular walls are thickened. The muscle
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ON RHEUMATIC CARDITIS IN CHILDHOOD. I97
may be pale, but naked-eye changes are usually insignificant.
There may or may not be evidences of pericardial or endocardial
infection ; more often than not such lesions are present, but of
no great gravity. Sections of the myocardium show perivascular
areas of leucocytosis with proliferative inflammation of the
stroma, leading eventually to a permanent fibrosis ; and in the
parenchyma loss of striation and fatty change.^
Three of the cases I examined post-mortem had during life
presented those signs which have been already described ; in
two of them there was in addition a pericardial rub, and in these
two there was an early fibrinous pericarditis. In all three the
valves were inflamed — the mitral in three, the aorta in two, and
tricuspid in one ; the lesions were of the usual type, circumscribed
nodules capped with a little fibrin. In none of the three, however,
were these lesions sufiicient to account for death, or even for
cardiac embarrassment ; but in all three there was considerable
ventricular dilatation, associated with some thickening of the
muscle, and with the microscopicsd appearances already men-
tioned as occurring in the myocardium.
In the fourth case there were similar myocardial and valvular
changes, but in addition there were lesions of the pericardium,
which during life had notably altered the physical signs from those
already described. The modifications which may thus arise from
special types of inflammatory change in the serous layers remain
to be outlined.
In both endocardium and pericardium the reaction to rheu-
matic infection may for convenience' sake be divided into three
stages : the acute, the recurrent, and the cicatricial. It is with
the first two that childhood is mainly concerned. In the peri-
cardium (to consider the first) there is a more or less acute reaction
to the first invasion, which occurs, of course, by way of the coronary
circulation ; as this subsides the fibrin which has been thrown
down is partly reabsorbed and partly used as the basis for new
fibrous tissue. Recurrences (or recrudescences) take place
repeatedly, and the pericardial sac is gradually obliterated ; but
^ See papers by Poynton (Lancet, 1900, i. 1352), Fisher (Lancet, 1902,
i- ^594)1 West, Herringham, Carpenter and others.
Digitized by VjOOQIC
198 DR* CAREY COOMBS
it is only when there are also pericardio-mediastinal adhesions that
really grave and specific effects are produced, and in such cases
cardiac failure is much more likely to occur than in the absence
of this complication. Clinically, the acute is not the commonest
phase of rheumatic pericarditis in childhood : only one true
example occurred in my sixty-five cases. It is characterised by
rapid increase in the area of cardiac dulness, which is due to
ventricular dilatation, and not to effusion of fluid (which, as
Poynton^s figures show, is rare, if not unknown, in rheumatic
carditis), and by a friction sound over the whole praecordium. It
appears to terminate in resolution, but in reality it leads to the
first instalment of those obliterating adhesions already spoken of.
The recurrent stage is commonest clinically ; it was exem-
plified by six of my cases, five of whom were boys. Slight pyrexia,
with dyspnoea and perhaps cardiac pain, leads to an examination
of the heart, which is found dilated ; friction sounds are heard,
often for a day or two only, over a limited fraction of the prae-
cordiimi, and the whole attack soon subsides. Probably its real
nature is often overlooked, especially as the rub may be pleuro-
pericardial and respiratory in rhythm.
There was no good example of the cicatricial stage among my
sixty-five children ; adhesions strong and dense enough to pro-
duce systoUc recession take so long in building that childhood is
gone before signs appear. My fourth autopsy was, however,
upon a case of this type, a boy of 13, admitte,d to the Bristol
General Hospital under Dr. Michell Clarke. The heart was j
encased in a dense mat of adhesions, fully half an inch thick }
over the ventricles. Myocarditis was proved by microscopy, and J
the valves were beaded. The adhesions bound the pericardial I
layers together and the heart as a whole to the surrounding ;
tissues. This boy had during life shown unmistakable systolic |
recession.
Rheumatic infection of the endocardium is usually limited by
the local reactive processes to the deeper parts of the valves,
where it arrives by way of the coronary circulation ; circum-
scribed nodules are formed, and permanent cicatrisation generally,
if not invariably, follows. Sometimes, however, the resistance |
Digitized by VjOOQIC
ON RHEUMATIC CARDITIS IN CHILDHOOD* 199
is lowered either locally by preformed fibrosis, or generally by
some malnutritive state, and the organisms find their way to the
surf ace Jof the valve, forming an infective ulcer, " pointing," in
fact, into the cardiac cavity. How is the first type, the commoner
circumscribed form of endocarditis, to be linked with the extreme
cicatrisation seen in ordinary mitral stenosis ? Is there constant
irritation by a latent infection, or are there repeated reinfections ?
This" cannot as yet be answered ; all that can be definitely said
is that advanced cicatrisation is not common before the age of 16.
Clinically, the circumscribed t5^e of rheumatic endocarditis is
perceptible in its acute stage only when the aortic valves are swollen,
and by no means always then. The only evidence is a diastolic
bruit, usually very indistinct, for the cicatricial stage must be
reached before the ordinary signs of aortic insufficiency are noted.
In at least one of my cases an aortic regurgitant murmur appeared
and disappeared again in so shorl: a time as to leave an impression
of subsiding inflammation* which had temporarily crippled the
valve. A similar affection of the mitral valve produces no special
signs, as the valve is already incompetent by reason of myocardial
weakness. The systolic murmur is myocardial, and not endo-
cardial in its origin.
The malignant type of rheumatic endocarditis was not repre-
sented among my cases. Figures bearing on its frequency will
be found in the writings of Osier ^ and Glynn. ^
The recurrent and cicatricial stages of rheumatic endocarditis
make themselves apparent only by thfe disablement of the valves
which they produce. For all practical purposes we may consider
aortic incompetence and mitral obstruction as the two perversions
of the valvular functions resulting from such disablement ; and
neither of these conditions is common, in well-developed form,
in childhood. A presystolic murmur and thrill do not necessarily
mean mitral stenosis in rheumatic children. Post-mortem, the
valves are usually found to show evidence of early fibrosis, but
the condition is quite unworthy to be classed as *' stenosis." It
is not surprising, therefore, that in none of my cases was an
unmistakable stenosis present. No doubt many of them will
^ Goulstonian Lectures, 1885. ^ Lumleian Lectures, 1903.
Digitized by VjOOQIC
200 .RHEUMATIC CARDITIS IN CHILDHOOD.
show it in later years ; but it had not had time to develop
at i6.
Aortic incompetence was present in thirteen out of my sixty-
five cases, but this must not be taken to indicate a preponderance
of aortic over mitral lesions as the effect of rheumatism. It
simply means that the aortic valves are easily and quickly
rendered incompetent, while it needs a good deal of fibrosis to
obstruct the mitral orifice. As a matter of fact, rheumatism
attacks the mitral valves nearly three times as often as the aortic
(Poynton), a figure supported by some observations of my own.
Of 155 cases of valvular disease examined by me at St. Mary's
Hospital, there were 99 purely mitral cases, 34 purely aortic ; of
the former 82 per cent, gave a history of acute rheumatism, of
the latter 35 per cent. only. The remainder were cases of com-
bined aortic and mitral disease, of whom 77 per cent, gave a similar
history.
There is no space here for a discussion of the prognosis or of
the lines of treatment. The object of the paper is to show that
for the production of those signs which are met with in the great
majority of cases of rheumatic carditis in childhood it is quite
unnecessary to blame the valves or the pericardium ; the myo-
cardial changes which are always present are enough to account
for everything. There are, however, modifications of the funda-
mental clinical picture due to special types of inflammatory change
in the serous layers. Of these the commonest are aortic incom-
petence and recurrent pericarditis, which, I may add, not m-
Irequently coincide in the same patient.
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TREATMENT OF GRAVES^S DISEASE BY ANTI-
THYREOID SERUM AND BY X-RAYS, i
J. MicHELL Clarke, M.A., M.D. Cantab,, F.R.C.P..
Professor of Medicine, University College, Bristol ; Physician to thr.
Bristol General Hospital.
It may be well, betore passing to the subject of treatment, to
recall briefly the chief theories as to the nature of Graves^s disease.
Unfortunately the pathology of this affection is still very obscure,
and the exact way in which it is produced uncertain.
Undoubtedly many of the most striking symptoms are brought
about through the medium of the sympathetic, but there is no
evidence that the disease originates in an affection of the sympa-
thetic ; and similarly, though the three cardinal symptoms have
been produced by experimental lesion of the restiform bodies, and
though there is even a stronger point in favour of the theory which
would attribute the disease to a lesion of the medulla oblongata,
namely that morbid changes are fairly constantly found there,
there is no sufficient proof that these lesions cause Graves's disease
or are more than secondary ones. The theory that it is due to
hypersecretion of the thyroid has perhaps more to support it,
Myxoedema is in some respects the antithesis of Graves's disease,
and we know that the former depends on an absence of the
thyroid secretion. Again, much has been made of the resemblance
between the symptoms of Graves's disease and those produced by
an overdose of thyroid extract ; but though there is a certain
analogy between the two conditions, it must be objected that no
one has ever yet succeeded in producing the full clinical picture
of Graves's disease by administering thyroid extract.
It was on the supposition that the disease depended on a
^ Read at a meeting of the Bristol Medico-Chirurgical Society held
at Weston-super-Mare on June 12th, 1907.
Digitized by VjOOQIC
202 DR. J. MICHELL CLARKE
hypersecretion by the th5n:oid that Mobius advised the use of
serum from th5n:oidectomised goats. He supposed that in the
serum of such animals there would accumulate an excess of anti-
bodies (to the thyroid), and that these, when ingested by the
patient suffering from Graves's disease, would neutralise the excess
of th3Toid secretion in them.
Numerous observers have published good results obtained
from the use of such sera. The serum was at first injected, but
was afterwards found to be equally efficacious by the mouth.
Good results have also been alleged from the use of Rodagen^the
milk of th3Toidectomised goats — ^given in the form of tablets.
I give my experience of the use of these remedies below. Of
the new serum prepared by Rogers and Beebe I have had no
experience ; their method is also founded on the thyroid hyper-
secretion theory- of Graves's disease, but based on a different
principle. They first endeavoured to find out how the thyroid
secretion in this disease differs from that in health, obviously a
most important point, and one not satisfactorily settled. As a
result of an extensive investigation, Oswald says that the only
difference between the two is that the thyroid secretion in Graves's
disease contains less iodine. The objects at which Rogers and
Beebe aimed are (i) to neutralise toxic substances, and (2) to
stop their production in quantity. From the nucleo-proteids of
certain organs they prepared a serum which had a specific cytolytic
effect on these organs, by inoculating rabbits (i) with nucleo-
proteids and thyroglobulins from the thyroid glands of fatal
cases of Graves's disease, and (2) with the same substances from
normal thyroids. After a definite number of injections, the
activity of the serum of these animals was determined by an
agglutinin test and injections made into patients with Graves's
disease. They claim that of the cases thus treated 11 were cured,
43 improved, and 15 were unaffected.
I have treated three well-marked cases of exophthalmic goitre
with Rodagen ; the patients improved — but I think not more
than most cases improve by rest in hospital — ^and I was not able
to trace any distinct effect from the remedy. I give the details
of one case.
Digitized by VjOOQIC
ON TREATMENT OF GRAVES*S DISEASE. 203
Case 1. — Rosina H., aet. 26. Duration of thyroid swelling,
tachycardia, and tremor with general weakness, &c., nine years.
Exophthalmos first appeared eighteen months previous to ad-
mission. Her condition has varied from time to time, being
sometimes better, sometimes worse ; after each of her two con-
finements she was decidedly worse. On admission she had
marked exophthalmos, pulsating goitre and tremor ; pulse-rate
140. The heart was slightly enlarged, and there was a systolic
apex murmur. For the first week, under ordinary treatment by
rest, phosphate of soda and glycero- phosphates, the patient felt
better, and the pulse-rate was from 118 — 130. From November
29th to December 12th Rodagen was given in half-drachm doses
three times a day. The pulse varied from 118 — 130 ; the neck
measurement remained the same. The patient declared herself
to be feeling decidedly improved, and there was obviously a general
improvement in her condition. From December 12th to 20th
Rodagen was stopped without making any apparent difference,
and was given again from December 20th to January 23rd. The
pulse-rate remained the same, proptosis and thyroid enlargement
unaltered, hearths action less excited. There was less tremor,
and she said the palpitation was less. As a result of the seven
weeks* treatment she gained 8 lb. in weight. Subsequently this
patient was treated with Mobius's antith5n:eoid serum, in a dose
of 5 cc. daily for about three weeks. The patient continued to
show improvement on her state on admission.* The tremor be-
came decidedly less, and the pulse-rate 112 — 120. No other
objective sign of improvement was noted, but she stated that she
felt very much better.
The following cases were treated with antithyreoid serum
(Mobius) : —
Case 2. — Louisa B., aet. 36, married. Never good health.
Duration of illness, two years. Goitre, palpitation, exophthalmos,
tremor. No cardiac enlargement, no apex murmur. Dyspepsia
and vomiting, throbbing of vessels. Admitted March 15th, 1907.
Pulse-rate 140 on admission ; this with rest dropped to 106 in
six days. Neck measured thirteen inches in circumference.
March 21st : Antithyreoid serum 5 cc. every other day, and ;
bismuth mixture for indigestion. On April 3rd condition much j
the same, but pulse-rate 96. She said her neck felt smaller, and
it was one inch less on measurement. April 9th, pulse 120. As
she said she did not feel so well, and that the heart beat faster
after taking the serum, the pulse-rate was taken every hour for
eight hours after the dose. It was found that no essential
difference could be made out in the pulse-rate after the dose from
that on the days that she did not take the serum. The only change
was, that on the average the pulse-rate on four occasions was
Digitized by VjOOQIC
204 DR. J. MICHELL CLARKE
about 10 beats to the minute slower for some hours after the
serum, viz. 112 — 114 instead of 124. On April 17th pulse-rate
was 112, perspirations were less profuse, tremors same, general
condition was improved. Five cc. antithyreoid serum had been
taken every other day from March 21st to April 3rd ; 10 cc. from
April 3rd to April i8th. The following estimations were made
of the nitrogen in the food and urine ; that in the faeces was not
determined ; the bowels were moved regularly once a day, and
there was no diarrhoea. On April 17th 10 cc. serum were given,
and she had been taking it since March 21st. Her weight was
45 kilos. The food, taken on this day contained 1,800 calories ;
the nitrogen in the food was 147.5 grains, and nitrogen excreted
in urine 126.7 (as urea and in purin bodies separately estimated).
On a later day, when no serum had been taken for three days,
she took a larger amount of food — over 2,300 calories — ^and the
nitrogen ingested and excreted, estimated in the same way, was
respectively 176 and 140 grains.
Case 3. — Margaret E., aet. 18. This patient was in the Hospital
in the autumn of 1906 with hysterical mutism, anorexia nervosa,
tachycardia, tremor and exophthalmos. She was profoundly
emaciated, weighing 5 st. 10 lb., whilst her height was 5 ft. 10 in.
Under Weir-Mitchell treatment, her weight went up to 8 st. 9 lb.
She left the Hospital after three months with a pulse of 140.
There was then no thyroid swelling, but this appeared shortly
afterwards. Readmitted March 28th, 1907, she was well
nourished, with marked exophthalmos, pulsating goitre, tremor,
profuse sweats, and loss of power in the legs. Pulse-rate, 140 ;
heart slightly enlarged, with a loud systolic murmur all over the
praecordia. She was ordered antithyreoid serum in dose of 5 cc.
every other day. After a week this dose was given daily, and
then she took 10 cc. every other day for another week, and during
the fourth week 10 cc. every day. Duration of treatment, April
1st to 28th inclusive. No appreciable effect was noticed during
the time the serum was administered. On April ist, on beginning
treatment, pulse-rate was 144 ; on April 7th it was 140 ; on 17th
it dropped to 112 ; but on April 24th was 150, and on May I5tb
was 150 ; on June 5th, 135. The respiration was 30. Sweats
remained undiminished ; exophthalmos same. The goitre— a
large one, circumference of neck being fifteen inches — ^was un-
altered ; tremor perhaps less. On the other hand, she expressed
herself as feeling better and stronger, and suffering less from
palpitation ; she slept better, and her appetite improved. The
quantity of urine averaged 44 — ^45 oz. per diem at the commence-
ment of the serum treatment ; dropped to about 30 oz. per diem
at the end of it, and for three weeks afterwards. This patient was
paraplegic ; the paraplegia, which presented some of the features
of hysterical paraplegia in the absence of muscular wasting, of
Digitized by VjOOQIC
ON TREATMENT OF GRAVES'S DISEASE. 205
alteration of the reflexes, of dulling of sensation to pain (pin-
prick) and of the muscular sense, did not improve under serum
treatment. The patient developed a very large appetite ; her
weight was 9 stone. On April 17th, i8th, the amount of food
taken was as follows : —
17th. i8th.
Nitrogen in food . . . . 204.2 grains. 197.6 grains.
Nitrogen excreted in urine
(urea and purin bodies) . 206.7 „ 211. 5
The nitrogen in the faeces was not estimated ; there was one
daily action of the bowels, so that apparently there was some
loss of nitrogen during the time the serum was taken. On May
5th, about a week after serum had been discontinued :
Total nitrogen in food 223 grains.
Nitrogen excreted in urine . . . . 212 „
Case 4. — Gladys J., 19 years. First symptoms : goitre, ex-
ophthalmos, palpitation, appeared six to seven months previous
to admission. On admission there were a large pulsating goitre
with thrill, a moderate degree of exophthalmos, a marked tremor,
and tachycardia. Pulse 132, no enlargement of heart, a systolic
pulmonary but no apex murmur, and anaemia. Under six weeks'
treatment by rest, constant current to neck, strophanthus,
belladonna and iron, little or no improvement took place. Pulse-
rate averaged 140. From September 14th to 28th she was given
antithyreoid serum 5 cc. every other day, all other treatment
being stopped. At. the end of this time there was slight improve-
ment, consisting of less pulsation in the thyroid, with a diminution
in the circumference of the neck from fourteen to thirteen inches,
less tremor, and a pulse-rate of 130 — 124. In other respects the
condition was unchanged, and she left the Hospital at her own
request a week later without any very material change in her
state.
Case 5. — ^Lily T., aet. 26. Symptoms attributed to a fall in
August, 1905, when she struck her head, and was in bad health
for some time afterwards. Tachycardia, exophthalmos and goitre
appeared November, 1905. On admission, April, 1906 : pulse
no, no cardiac enlargement or .murmur, marked tremor,
sUght exophthalmos, and small goitre, chiefly of right lateral
lobe of th5n:oid. She suffered from constant profuse perspirations.
Blood pressure, 120 mm. Hg. From April 5th to 30th, 1906, she
was treated by rest in bed, by antith3Teoid serum, si, given
twice daily ; and, as she slept badly, an occasional dose of
Veronal at night. This was a mild case. She certainly improved
under treatment ; the pulse-rate fell to 88 — 98, the blood pressure
to 105 mm. Hg. There was less tremor, less exophthalmos ;
her general condition improved ; she became less nervous, and
Digitized by VjOOQIC
206 DR. J. MICHELL CLARKE
recovered her sleep. On the other hand, the profuse perspirations
were unchanged. She gained a few pounds in weight. After
April 30th the an tith5n:eoid serum was stopped, and she was given
belladonna, with application of a constant current to the neck.
There was no material change in her state, the improvement being
maintained, but she varied from day to day, having bad days, in
which the palpitation was again severe.
In the following cases treatment was by X-rays : —
Case 5 remained in much the same state until August, 1906.
From August nth to November loth she was treated by X-rays,
attending as an out-patient three to four times a week for that
purpose. The X-rays were applied over the thyroid gland for
ten minutes at each sitting, thirty-four sittings in all. No
distinct effect was observed from this course of treatment, except
that there was some diminution in the size of the goitre.
Case 6. — Ida N., aet. 27, was treated by X-rays. Admitted
July 31st, 1906. She had had no pre\HOus illness, except rheumatic
fever two years ago. The present illness began three years ago
with a pulsating goitre, palpitation and tachycardia. This attack
lasted six weeks, and was relieved by rest at a convalescent home.
Symptoms returned March, 1906, and continued until admission.
On examination there were a large pulsating goitre, marked
tremor, slight exophthalmos, pulse-rate 108, pigmentation
of upper eyelids, and a systolic murmur at apex. From August
4th to September 19th she was treated by application of X-rays
to the thyroid on four days a week, for ten miriutes at each sitting.
At the end of this time the neck measured about the same, pulse-,
rate 112, pulsation in vessels same, tremor decidedly less.
She had lost 4 lb. in weight. She said herself that she felt better.
The X-rays were then omitted for a week without any material
change in her condition, except that she gained 2 lb. in weight.
Treatment by X-rays was resumed on September 26th, and con-
tinued until November loth ; during this time she was an out-
patient. She gained weight slowly but steadily during this
period, gaining 6 lb. in all. Her pulse remained at 108, the
tremor was still present but less. Sleep was good, and she had
a good appetite, but suffered from dyspepsia. On the whole,
slight general improvement.
Case 7. — Nellie B., aet. 23. Illness stated to have begun six
months previously. She had taken thyroid extract for psoriasis.
On examination there was left-sided exophthalmos, slight left
ptosis, a large pulsating goitre, pulse-rate 125 — 130, marked
tremor, profuse sweats and general nervousness. Treatment with
X-rays was carried out in the same way as in the other patients,
forty-three sittings being given in all between August loth and
Digitized by VjOOQIC
ON TREATMENT OF GRAVES'S DISEASE. 20/
November 3rd, 1906. In this case the pulse-rate fell to an average
of 116 in October and to 98 — 100 in November, the goitre
became smaller, the tremor and sweats less, and the patient felt
generally better.
Of another case treated by the X-rays for six weeks I need
not give the details, as although a diminution in the size of the
thyroid, and a temporary fall in the pulse-rate occurred, except
for the former, there was no permanent alteration in the patient's
state as a result of treatment.
There is great difficulty in estimating at its true value any
mode of treatment of Graves's disease. The malady is not a fatal
one ; in a case of average severity it may not materially shorten
life. It is not steadily progressive ; remarkable ameliorations
occur in the natural course of the illness, and these remissions
may last a long time. Further, most of the symptoms are directly
produced by functional disorders of the nervous system. For
many of these we have to depend on the statements and on the '
subjective feelings of the patient ; and even of those which can be
objectively observed, some are of such a nature as to be influenced
by nervous states. The symptoms generally are easily affected by
changes, for good or bad, in the general conditions of life. In hospital
in-patient practice the effect of treatment is particularly difficult
to judge, for the improved conditions arising from good food,
rest, freedom from harassing family cares, well- ventilated wards,,
and general care to maintain the bodily functions in good order,
nearly always result in considerable improvement in the patient's
health, and are just those best adapted to counteract the
disabilities of the disease.
On looking over notes of old cases treated simply by rest, a
full diet, tonics, belladonna, and electricity to the thyroid gland,
I find that in nearly every case the patient went out better.
This statement must be modified to the extent that no patient left
the Hospital cured. Goitre, exophthalmos, pulse-rate, tremor,
sweats, might all be less, but still remained to some extent. Thus
I do not find a pulse-rate below 90. The S5miptoms most com-
pletely relieved were " nervousness," tremor, palpitation or
subjective sense of pulsation in vessels, sweatings, and sense of
Digitized by VjOOQIC
208 TREATMENT OF GRAVES'S DISEASE.
suffocation or difficulty of breathing from enlarged th5n:oid, and
together with this relief a general increase of strength and of
well-being.
Compared with the ordinary results of hospital treatment,
I did not find any striking advantage from the use of antith5Teoid
serum, though it must be said that the patients certainly declare
themselves as feeling much better, more than they usually do
under ordinary treatment. So far as I am aware, they did not
know that they were taking a new remedy. There was no
■especial point to notice, except that in two of the cases, so far
as observations went, there was , an increase of nitrogenous
excretion by the urine, and in one the quantity of urine passed
was decreased. The expense of the serum is a decided dis-
advantage.
With regard to the X-rays, more experience is required; as
the patients were out-patients, the treatment by X-rays was
the only change from their ordinary condition. In one case,
which was anomalous in its alleged mode of origin, their use ap-
peared to be attended with marked and permanent benefit.
The others ** felt better," and there was a slight diminution in
pulse-rate during treatment, which was not, however, permanent.
In one respect I think the X-rays may be of advantage, and that
is in diminishing the size of the goitre ; this diminution was
permanent in three cases, and with it the patients lost the feeling
of suffocation, of which they had occasionally complained. In
one patient there were marked fluctuations in weight ; but though
weight was lost during a first course of X-rays, it was gained during
a second. Such fluctuations also occur, with remissions, in the
natural course of the disease.
It may be added that in each case the urine was normal, and
that, from what is now known of treatment by X-rays, it would
probably be inadvisable to use them in any case where the kidneys
were not sound.
I am much indebted to my colleague. Dr. W. K. Wills, for
the care with which he carried out this part of the treatment.
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CEREBRAL LESIONS IN PREGNANCY AND
PARTURITION.
Walter C. Swayne, M.D., B.S.,
Professor of Midwifery, University College, Bristol ; Obstetric Physician,
Bristol Royal Infirmary.
Organic cerebral lesions may occur in the course of pregnancy
and parturition with the same relative frequency as in the absence
of these conditions, but their coincidence may, under certain
circumstances, give rise to considerable difficulties in diagnosis.
In addition to symptoms due to organic lesions of the brain
and cord, several forms of neurosis may occur which simulate
them in a greater or less degree, and give rise to difficulties in
diagnosis and treatment which may lead to mistakes, both in
treatment and prognosis, of a character by no means trivial.
The position is also complicated by the fact that various
functional neuroses, with symptoms superficailly resembling those
of organic cerebral lesions, are liable to occur during both preg-
nancy and the puerperal state, e.g. affections of speech, apparent
loss or impairment of vision, affections of hearing and paretic
conditions are met with not infrequently ; while inflammatory
cerebral lesions, with their accompanying symptoms in the puer-
perium, will almost certainly be attributed in the first instance
to uterine sepsis, with which, it must be stated, there is occasionally
a definite causal connection. Paralyses of the lower limbs alone
are not infrequent, owing to the UabiUty of the nerve tissues in
the pelvis to mechanical pressure ; these may be attributed to
lesions of the cord, and it is not unknown for cases superficially or
even intimately resembling, e.g.^ spastic paraplegia to arise, or at
any rate to display their first symptoms after parturition. The
writer has quite recently met with a case of this kind, in which
paraplegic symptoms with spastic phenomena supervened on a
A^OL. XXV. No. 97. ^ ,
Digitized by VjOOQIC
210 DR. WALTER C. SWAYNE
difficult labour, but proved on careful investigation not to be due
to a definite descending spinal lesion, the symptoms of which they
much resembled.
Such cases as this do not come within the purview of this
paper, which is concerned more especially with cases in which the
symptoms indicated an organic cerebral lesion.
Case 1. — ^A multipara, aet. 37, was delivered by a midwife,
who summoned the writer on the day following delivery because
the patient was paralysed. I found her to be suffering from
marked right-sided hemiplegia, with interference with speech.
She was quite unable to articulate distinctly ; although she would
make attempts to pronounce the words she wished to use, she
could not do so in such a way as to make them recognisable.
Some facial paralysis was present. The whole condition cleared
up in about ten days, the paralysis passing off and her power of
articulation returning. The lesion was regarded as being due to
a thrombosis of the left middle cerebral artery or one of its
branches.
Case 2. — A multipara, aet. 22, was delivered on the 27th of
January, 1901, labour being normal in every respect. Two days
later, during which time she had suffered from severe headache
and rise of temperature, which was attributed to septic infection,
and for which her uterus was washed out, she became comatose,
and died very shortly afterwards. An autopsy was made, and to
the surprise of everyone concerned pus was found over the whole
upper surface of the cerebral hemispheres and anterior third of the
cerebellum ; also between the lobes of the cerebellum and along
the whole length of the cord. Numerous cocci were found in the
pus, including a diplococcus which stained feebly with Gram.
The cause of death was obviously suppurative cerebro-spinal
meningitis.
Case 3. — ^A patient who was at about the end of the seventh
month of pregnancy was admitted into the Bristol Royal Infir-
mary in a state of coma. She had some slight convulsive move-
ments, her urine was albuminous, temperature 102° F., pulse no,
and respirations 50 ; a little later her temperature was 103° F.,
pulse no, and respirations 72, the coma increasing. She was wet-
cupped at once, and the usual remedies for eclampsia used in the
interval between her admission and my seeing her. On seeing her,
I expressed a doubt as to her suffering from eclampsia, and
hazarded the suggestion that she was in reality suffering from an
inflammatory cerebral lesion, possibly meningitis ; but of this
there were no definite symptoms, except that her general aspect
and the character of the convulsive movements reminded me of
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ON CEREBRAL LESIONS IN PREGNANCY AND PARTURITION. 211
the appearance of children suffering from meningitis. She
delivered herself twenty hours later of a premature stillborn
child, and died four hours later. Post-mortem : Suppurative
meningitis of the brain and cord was found. The pus contained
numerous staphylococci, and in addition a diplococcus resembling
Fraenkel's.
Case 4. — ^A multipara, aged about 40, was admitted in a state
of coma, with convulsive movements and albuminous urine, as
suffering from eclampsia. She was in the ninth month of preg-
nancy, and was delivered by accouchment forcee but died
withm two hours of delivery. Post-mortem : There was found
at the upper part of the right temporal lobe a cyst filled with fluid
as big as the fist, and a second cyst of less size was found in the
lower right frontal lobe. The kidneys were granular.
Case 5. — A multipara, aged 28, on the tenth day after delivery
developed a temperature of 103° F., after a convulsive seizure,
which was chiefly marked on the left side ; her temperature
gradually rose, and she rapidly became comatose, but no more fits
occurred. When I saw her there was an occasional tremor of the
left arm and leg, associated with marked rigidity of these limbs,
deviation of the eyes to the right, and some facial paralysis. She
had suffered from a discharge from the right ear. She died about
eight hours later, and no autopsy was made. This was probably
a case of cerebral abscess with rupture following on middle ear
disease.
From a practical point of view, the importance of these cases
resolves itself into considerations of diagnosis and prognosis, since
in the last case only could treatment have had any marked effect.
In Case i there was no great difficulty, except that either the
hemiplegia, affection of speech, or facial paralysis might, if they
had existed alone, been possibly functional.
The presence of these three conditions simultaneously, how-
ever, appeared to me to indicate a gross cerebral lesion, while the
comparatively rapid recovery and the fact that the paralyses and
affection of speech were not absolute seemed to me to point to a
thrombosis rather than an embolus or hemorrhage.
In Case 2 the only clue to the real source of the symptoms lay
in the acute headache and ingravescent coma, with high fever.
In such a case one's first thought would be naturally that
uterine sepsis was the cause, the only possibility of excluding
Digitized by VjOOQIC
212 DR, WALTER C. SWAYNE
which would be to prove that the uterus was germ-free by culture.
Cerebro-spinal meningitis was never dreamt of as a possible cause
of the s5miptoms, or a lumbar puncture would in all probability
have cleared up the diagnosis. One point in connection with this
case is worth recording : in the majority of cases in which suppura-
tive cerebro-spinal meningitis has been found as a complication
of the puerperium uterine sepsis has been present.
This, after all, is not surprising ; but the rapid death in this
case almost precludes that possibility, while at the autopsy no
focus of septic infection was found. There is no record as to
whether a culture was taken from the uterine cavity.
The infection must almost certainly have been present at the
time of dehvery, as the patient was complaining of headache then.
In the third case a quite justifiable diagnosis of eclampsia was
made. I did not agree with this, in spite of the albuminous urine,
because the so-called fits in no way resembled eclamptic seizures
as I have seen them, and, moreover, in eclampsia a markedly
febrile temperature does not as a rule occur except after several
fits, and when it does is of very grave prognostic import.
The rapid respirations rather suggested pneumonia, but no
physical signs could be found.
None of the usual symptoms attributed to meningitis were
present in any noticeable degree, and I greatly regret that, having
hazarded the suggestion that cerebro-spinal meningitis was the
cause of the trouble, I did not at once proceed to verify this by
lumbar puncture.
In Case 4 the fits were probably eclamptic, and the cysts
present simply a coincidence.
In Case 5 the febrile temperature, increasing coma, left-sided
spasm and rigidity rather indicated the presence of a localised
cerebral inflcmimatory process than an attack of eclampsia, which
was the provisional primary diagnosis. In this case possibly
surgical intervention might have succeeded had her condition
been such as to call the attention of her medical attendant or to
alarm her friends earlier. As it was, her own attendant was not
sent for until she was obviously very ill, and when I saw her she
was moribund.
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ON CEREBRAL LESIONS IN PREGNANCY AND PARTURITION. 213
Prognosis, — In any case similar to those mentioned above
prognosis cannot be too guarded if a gross cerebral lesion is
probable, and especially if it appears to be of an inflammatory
origin. Whether in connection with pregnancy or not, this may
be looked upon as the rule.
A mistake in diagnosis is quite likely, and in the majority of
such cases quite pardonable, even with a practitioner of experience.
In the cases of meningitis it is extremely doubtful if an accurate
diagnosis would have been of the least value.
It is barely possible that the injection of an antiseptic through
the lumbar puncture might have some effect ; in any case it could
hardly hasten the certain fatal event ; or it is again possible that
injection of a polyvalent serum might prove of some use, or at any
rate of little harm. The rapid fatality of the affection gives but
little time for anything of the kind, however, and in these cases
one important point is to be remembered — that whatever is to be
done should be carefully and clearly explained to the« friends, who
are particularly prone to misinterpret unsuccessful efforts in these
cases, and who are most obstinate and unreasonable in sticking to
their own opinion as to the cause of death.
As an example of this, I may mention a case of which I have
known, in which the patient dying of cerebral hemorrhage shortly
after a confinement, in which she was given chloroform while
forceps were used, the anaesthetic has always been spoken of by
the friends as the cause of death, and the reputation of its
administrator made to suffer accordingly.
REFERENCES.
Galabin — Midwifery, 1904, p. 875.
Edgar — Obstetrics, 1903, p. 361.
Bolslini^re — Obstetric Accidents, Emergencies, and Operations, 1896, p. 160.
System of Gynecology and Obstetrics. Ed. by Mann and Hirst. Vol. ii.
part ii., 1889, p. 497.
Imbert-Gourbeyre, quoted by Hirst. Ibid., p. 627.
Morris and Dickinson — Text-book of Obstetrics, vol. ii., 1902, p 157.
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A SUGGESTED TREATMENT FOR FUNCTIONAL
APH0NIA.1
C Percival Crouch, M.B. (Lond.), F.R.C.S,
Hon, Surgeon, Weston-super-Mare Hospital,
The treatment of functional aphonia has always struck me as being
unsatisfactory.
In the majority of cases, of course, the voice can, so to speak,
be frightened back. The introduction of a mysterious instrument,
as the laryngoscopic mirror must appear to the uneducated mind,
in many cases serves the purpose. In other cases the more
severe treatment by the interrupted current effects a cure, but a
small minority of patients fail to benefit by any of the usual
methods, and often pass into a state of voicelessness which persists
for years, and often for life.
Now the frightening of the voice back always seems to me on
a par with frightening children into good behaviour ; it is un-
certain in its effect, and relapse is common. It is only systematic
treatment on definite lines which can be depended upon for any
permanent effect, either in the case of a naughty child or the ill-
behaving vocal cords ; and I venture to think that the treatment
I now advocate is based upon sound principles, and can be
successfully carried out by any medical man.
I have adopted it myself with success for the last four or five
years, and so far as I can ascertain it is a method which has not
hitherto been described for the cure of functional aphonia. Should
I, however, be mistaken in my assumption, I must apologise for
having inadvertently trespassed upon someone's preserves.
Before illustrating by specific cases, I would premise by saying
that the treatment is based upon the fact that in almost every case
there is some sort of a sound which can be produced by the approxi-
1 Read at a Meeting of the Bristol Medico-Chirurgical Society at Weston-
super-Mare, on June 12th, 1907.
Digitized by VjOOQIC
A SUGGESTED TREATMENT FOR FUNCTIONAL APHONIA. 215
mation of the vocal cords, and this note has, so to speak, to be
caught and educated. As a rule, it is a very high-pitched note —
C or D above — of the very feeblest quality, often not louder than
a mouse's squeak, and inaudible at a few feet away. It requires
great patience on the part of the doctor to catch and educate it.
In most cases the sound is more easily made with mouth almost
or quite shut. As the voice strengthens, the patients can gradually
open the mouth more and more, but any attempt to make them
start with a big, round mouth — as a singing master would advise
his pupils to do — is useless, and they themselves, as a rule, choose
to keep the lips fairly close together. Although the first sound
produced is usually very high-pitched, in one patient the only
sound I could elicit was a low-pitched grunt — about F below
middle C ; this is unusual, I believe. It is very desirable to siscer-
tain on the piano the note the patient first pitches on, either as a
squeak or as a grunt, and to record this note in a book, so as to
start on the same note the next lesson.
Sometimes it is not easy to make out what note a grunt is, but
you can get pretty close to it, and after a few trials the patient will
attune her voice to the note you have decided on as being nearest
to her first attempt. It is well to remember that it is easier to
" hum " than it is to pronounce a definite vowel sound, as " o '' or
" e." At the first interview you strike middle C on the piano,
telling the patient to try to sing or '* hum " to it. You then
strike D, E, F, G, A, B, C in quick succession. As a rule, with the
lower notes no sound beyond a gasp or whisper is heard, but when
upper B or C is reached the patient usually gives a momentary
faint squeak, which, if prolonged, relapses at once into a whisper.
At the first interview you must be contented with this momentary
feeble squeak. On the following day start at once on the note the
patient succeeded in producing the day before — ^say C above — at
first, as yesterday, being satisfied with a succession of short,
sharp, falsetto sounds, with intervals of rest between. After
practising the interrupted sounds for a few minutes, it is well to
hold the note on the piano down for a brief space, telling the
patient to continue to squeak as long as it is held down. At first
the sound is very tremulous, but by the end of the lesson, which
Digitized by VjOOQIC
\
2l6 MR. C. PERCIVAL CROUCH
IsLsts about ten minutes, it has usually become firmer, somewhat
like a miniature siren. If it does not become firm, go back for a
time to the interrupted squeaks. When the voice has thoroughly
grasped the siren or humming sound, and can sustain it without
breaking for a few seconds at a time, the vowel sound " o " should
be attempted, and as soon as that has been accomplished a word,
e.g. Do of the Do, Re, Mi should be learnt and sung on the
same note. When the " Do " is first attempted it often results
in failure, the voice breaking into a whisper again. Should that
be the case, let the patient pronounce it as two words, De (short)
O ; she will then whisper the first part, De, and sing the O, and
after a few trials will arrive at Do as one word. By this time she
will, as a rule, be able to take a lower note and a higher one, and to
sing the words Do, Re, Mi up and down on these three notes
till they are sung firmly and fairly loudly. If there is any diffi-
culty let her repeat the Do up and down, and soon the words Re
and Mi are learnt, as the voice strengthens and she gains confi-
dence. If the patient has anything of a voice the scale can soon
be managed, and after that, or before, if the patient is not a singer,
words can be intoned, and in reply to your questions the answers
must be intoned, so that the patient gradually learns to use a
large number of different words. After that she can try a simple
song, as ** Three Blind Mice," repeating the same sentence several
times running, and then pass on to intoning on a fewjiotes any piece
of reading you choose. When she can sing or intone easily any-
thing you give her, it is time to start speaking, and after practising
the singing voice for a few minutes tell her to read instead of
singing, starting with a simple sentence and repeating it very
slowly after you. If there is any hesitation, let her at once go back
to the singing, and try again. It may require two or three
attempts. After that she can practise reading aloud regularly at
home, but should always keep the voice in working order by daily
singing.
This is an outhne of the treatment, which can be modified as
occasion demands. It is very desirable while you are carrying
out this treatment in a severe case to isolate the patient, parti-
cularly if she happens to be living in the bosom of a large and
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ON A SUGGESTED TREATMENT FOR FUNCTIONAL APHONIA. 217
sympathetic family. If possible, let her stay with a nurse or any
sensible woman who will carry out your instructions conscientiously.
Strict orders should be given that she must not whisper at all, but
after she has learnt to intone permission may be given to use her
voice in conversation by intoning.
After the first two or three lessons, when she can sing Do, Re,
Mi, it is a good plan for her to practise these first three notes twice
or thrice a day for ten minutes at a time at the piano, her com-
panion striking the notes and insisting on their being sounded
firmly and steadily.
In the most severe case I had it took ten or eleven days before
she could speak at all vigorously. In mild cases two or three
visits may often suffice to restore the voice.
I will now illustrate by two cases, which I have taken as bad
ones.
Case 1. — ^A French lady, a teacher, about 23 years of age,
came to me on April 30th, 1902. She had lost her voice sixteen
months ago, and had' been treated at a throat hospital in town by
electricity, &c. She had naturally a very weak voice, and had
never sung. The only note she could produce was a high squeak
on C above middle C, and B next below not so well. Both these
notes were of the feeblest quality, barely audible a few feet away.
On attempting notes above or below B or C the voice at once
became a whisper. Three or four days later she succeeded in
producing upper B, C, D fairly strongly, and also A and G very
tremulously. I bade her practise these five notes — G, A, B, C, D
—thrice daily, and enjoined on her the necessity of not trying to
speak at all, but of asking for what she wanted in a sing-song on
upper C. Three days after that she sang fairly clearly from G up
to D, and at the same lesson spoke in a feeble voice. From that
date she improved rapidly.
Case 2. — ^A young lady, age 19 years, came to see me June i8th
1904. She had lost her voice six months ago. She was very
strong physically, and clever. Had had treatment, including
electric battery, without benefit. Could only speak in a whisper.
At the first interview the only sound I could elicit, after over a
quarter of an hour's trial, was a very feeble, low-pitched grunt,
about F below middle C, barely audible. No note in the nature
of a high-pitched falsetto note could be produced at this visit.
Three days later, on again making the grunt, the voice broke on to
a momentary falsetto squeak, just audible, on E above upper C.
On the following day she started at once on E above, and soon
Digitized by VjOOQIC
2l8 MR. J. PAUL BUSH AND DR. J, A, NIXON
produced all the notes by humming from upper C down to middle
C, but broke down at once into* a whisper when told to sing Do.
By pronouncing the Do as two words — De — O — she soon
succeeded in singing it as one word. The next day she sang the
octave, and in answer to various simple questions intoned the
replies. On June 26th, eight days after her first visit, after sing-
ing the octave and various sentences clearly for a short time, she
succeeded, with some difficulty, in speaking a simple sentence,
repeating the words after me very slowly. From this time the
voice got rapidly stronger, and I advised her to practise singing
every day to keep the voice strong.
These two cases I have chosen as they had both been treated
by experts in throats, and the battery had been applied in both
cases without success.
A CASE OF FILARIASIS:
REMOVAL OF LYMPHATIC VARIX BY OPERATION.
J. Paul Bush, C.M.G.,
Senior Surgeon to the Bristol Royal Infirmary,
AND
J. A. Nixon, M.B., M.R.C.P.,
Assistant Physician to the Bristol Royal Infirmary.
In October, 1906, a negro, aged 19, was admitted to the Royal
Infirmary under Dr. Nixon on account of elephantiasis. His
home had been in Demerara, where his parents, two brothers and
four sisters are still living and healthy ; one brother has died from
" diarrhoea." Previous to leaving Demerara he had suffered from
occasional attacks of fever, but during the last five years these
had been absent. He came to England two-and-a-half years ago,
and has followed many occupations — ship's steward, professional
boxer, and motor-car cleaner. About six months after his arrival
two abscesses appeared on his right leg ; they burst and healed
spontaneously without further trouble.
About seven months before he came under our observation, a
swelling in the left groin began to trouble him — not by pain,
merely by the discomfort of its presence ; its growth was slow
but steady. A month after the swelling appeared in the groin he
noticed that the left leg as a whole was increasing in size quite
Digitized by VjOOQIC
QN A CASE OF FILARIASIS. 219
painlessly ; he was also struck by the fact that both the general
fulness of the leg and the locahsed tumour in the groin increased
on standing and decreased after resting. On one occasion he
intentionally pricked the leg with a needle, and a milky fluid
escaped, but the puncture healed in a few days.
On admission the patient presented all the appearances of
vigorous health and considerable physical development. The
heart and lungs showed nothing abnormal. The pulse rate was
88, respirations 24, and the temperature was 97° F. His ab-
domen was soft, flaccid, and not distended ; the liver and spleen
were not enlarged. In the left groin, filling Scarpa's triangle and
apparently outlined by it, wa^ an elastic, irregularly-lobulated
swelling neither painful nor tender ; above it was very definitely
limited by Poupart's ligament. At first sight, and to the touch,
it represented a soft lipoma, but there was a marked impulse on
coughing. It had an ill-defined feeling of fluctuation, and by
pressure on one half could be almost completely made to disappear
in the part under compression, with a corresponding increase of
fulness in the other part ; it felt, in fact, like a wet sponge in an
india-rubber bag. When the patient lay down for a short while
the tumour became obviously smaller, and then irregular knotted
cords could be felt traversing its substance ; firm pressure on
the abdomen just above Poupart's ligament conveyed the im-
pression of a similar fulness in the pelvis on that side, which was
absent on the right ; no enlarged glands could be made out. The
thigh was not much increased in size, but below the knee there
was considerable oedema, with the characteristic hardness and
ruggedness of the skin which is associated with elephantiasis. At
the middle of the calf the girth of the left leg was four inches
greater than the right ; the skin was not broken or inflamed.
There was no sign of lymph scrotum, or of any varicosity of
lymphatics in other regions.
On the night subsequent to that of his admission the patient
had a rigor, and his temperature rose to 102° ; the attack was by
no means a complete or definite '* ague-fit,'' and never recurred
at any time. The temperature remained constantly normal
afterwards.
Mr. Rudge, our house physician, examined the blood, and
found the filaria sanguinis hominis present at nights ; the results
of his investigations are appended to this report in their entirety.
The swelling in the groin was explored shortly after admission
with a hypodermic syringe ; no fluid entered the syringe, but on
withdrawing the needle, a drop of milky fluid appeared at the
seat of puncture ; by pressure a considerable amount of chylous
fluid was procured, but on examination no filariae were found
(the time of puncturing was 3 p.m.). Rest in bed and the ap-
plication of pressure made no material difference. to the condition
of the leg.
Digitized by VjOOQIC
220 MR. J. PAUL BUSH AND DR. J. A. NIXON
It was then represented to the patient that an operation for
the removal of the tumour might be successfully undertaken, but
that the cure of his elephantiasis or the discovery of the parent
worm or worms (in whose life history he took a keen interest)
were improbable, the chylous nature cf the fluid making it
unlikely that the actual point of obstruction was low enough
down to be accessible. Understanding the circumstances, he
decided, that he would have the operation performed after Christ-
mas, and returned home for a month.
On January i6th, 1907, Mr. Bush operated for the removal of
the lymphatic varix. Turning up a large triangular flap of skin
in the grom, he exposed the mass, Hgatured the larger lymphatics
above and below as they entered the varicose plexus, divided the
internal saphena vein which was buried in the mass, and then cut
through its remaining attachments, excepting an extension of the
plexus which was found to pass through the saphenous opening,
communicating probably with similarly dilated lymphatics more
deeply situated. This was ligatured and divided, the varix when
removed being about large enough to fill a soup plate (the lymph
contained in its spaces having for the most part escaped) ; no
trace of the parent worm was found in it.
So far as was possible all oozing points in the area laid open
were ligatured before closing the wound, and a drainage tube was
inserted. No attempt was made to follow the lymphatics into
the pelvis and remove them from that situation, into which they
obviously extended.
The patient made an uneventful recovery, and left the Infir-
mary a month after the operation ; the wound was not completely
healed, and there was still a slight leaking of lymph. The general
swelling of the leg was somewhat less, and the patient expressed
himself as much more comfortable since the lump in his groin had
been removed. As he no longer resides in Bristol, we are not aware
whether the discharge of lymph has stopped and the wound healed.
The appearance of the iilaria in the blood was in no way
affected by the operation ; the embryos were found at the usual
time during the night in undiminished numbers from the date of
operation to the time of discharge. *
Since the publication of Cunningham's monograph (with its
extensive bibliography) ^ it seems of great importance that cases
of filariasis which are submitted to surgical treatment should be
reported in full, so that evidence may be amassed upon which
sound conclusions may ultimately be based. For at present, if
surgery fails to relieve the subjects of filariasis, they lie indeed
under no obligation to '* internal medicine."
^ Ann. Surg,, 1906, xliv. 481.
Digitized by VjOOQIC
ON A CASE OF FILARIASIS.
221
BLOOD REPORT BY F. H. RUDGE, M.R.C.S., L.R.C.P.
The examination of the blood of this patient has not
demonstrated any new facts as to the characteristics or life-
history of the filaria noctuma embryo. The presence or absence
of the embryo in the peripheral blood taken at various times
during the day and night is indicated in the appended table :
12 midnigh
it numerous.
12 noon .
. none.
2 a.m.
. . present.
4 p.m. .
. none.
4 a.m.
. . present.
6 p.m. .
. none.
5 a.m'.
. . present.
7 p.m. .
. none.
6 a.m.
. . few.
8 p.m. .
. present.
7 a.m.
. . none.
9 p.m. .
. present.
9 a.m.
. . none.
10 p.m. .
. numerous
II a.m.
. . none.
II p.m. .
. numerous
The advent of the embryos appears to be very rapid, as
indicated by the fact that while at 7.30 p.m. none could be found,
at 8 p.m. they were fairly numerous. Their disappearance was
equally abrupt. The number, which average about twelve in
a drop of blood equal to two minims, was greatest between the
hours of 10 p.m. and 2 a.m. On one occasion a solitary embryo
was found at 10.30 a.m. It was in every respect similar to those
found during the night, except that it was not so active. This
was after the l3miphatic mass in the groin had been removed by
operation. This was the only occasion when the worm was found
during the day, and may be regarded as purely accidental.
It is unusual to find two or more in close proximity ; in fact,
they appear to be particularly prone to remain aloof from each
other. Cold soon kills them, and their habit of leaving their
sheaths under its influence was frequently demonstrated. If kept
at body temperature, they would remain alive even under a cover-
slip for forty-eight hours. An attempt to stain them in situ
was made by giving the patient methylene blue pills, but although
this was continued for a week, it wsis of no avail. The nuclei
of the leucocytes were stained lightly. Empty sheaths were
frequently foimd, and were noticed to be more numerous when
the live embryo was not present.
Digitized by VjOOQIC
222
MR. L. M. GRIFFITHS
The result of the blood-counts was as follows : —
Red .
White
12 noon,
8,552,000
10,600
PER CENT.
Polymorphonuclear . . 59.8
Large mononuclear . . 14.6
Small mononuclear . . 9.4
Eosinophiles . . . . 12.8
Basophiles 2.5
12 midnight.
6,720,000
12,200
PER CENT.
53.24
12.23
17.02
13.29
4.35
This result only bears out what has already been described,
namely the presence of eosinophilia. It seems questionable
whether the increase in the eosinophilia when the worm was
present, though constant, is a point from which one can draw
any inference. If it were more marked, one might reasonably
assume that* the eosinophiles had a phagocytic action on the
embryos. The counts were made frequently, but the above
results are representative.
A microscopical examination of the chylous fluid obtained by
aspiration of the mass in the groin demonstrated that the filaria
was absent.
THE MEDICAL READING SOCIETY, BRISTOL.
L. M. Griffiths, M.R.C.S. Eng., L.R.C.P. Ed.
Rarely will it be possible to chronicle the doings for a
hundred years of a society that has never at any time had a
larger membership than twelve. But as the opportunity has
recently occurred in this city, such an event should not be passed
over without some comment, as the history of a Medical Society
during such a long period cannot fail to bring out many interesting
points.
Digitized by VjOOQIC
ON THE MEDICAL READING SOCIETY, BRISTOL. 223
On March 28th, 1807, some medical men of Bristol decided to
forai " The Medical Reading Society, for the purpose of pro-
moting medical knowledge and a friendly intercourse among its
members, and for purchasing medical books." Some practical
rules, very similar to those of most book or magazine clubs,,
received the approval of these eleven members : — ^
Thomas Jermyn, Surgeon and Apothecary, 17 Queen
Square. "^
Henry Daniel, Surgeon, 52 Queen Square.
Richard Edgell, Surgeon, 68 College Street.
Benjamin Spencer, Surgeon and Apothecary, Paul Street,.
Kingsdown.
William Mortimer.
Robert Lax.
Benjamin Gustavus Burroughs, Apothecary, Portland
Place, Clifton.
Joseph Maurice, Apothecary and Man-Midwife, Upper
Maudlin Lane.
William Hetling, Surgeon, 18 Orchard Street.
Nathaniel Smith, Surgeon, 34 College Green.
John Bishop Estlin.
^ The names are given in the order in which the signatures to the rules
occur. The descriptions and addresses are from Mathews's Bristol Directory
for 1807. In this the names of Mortimer and Lax are not given, but in the
iSoS Directory Lax appears as "Surgeon & Apothecary, 11 Queen Square,"'
and in that for 1809 there is an entry of " Berjew and Mortimer. Surgeons
& Apothecaries, 17 Bridge Street." The name of Estlin, who was the son
of the Rev. John Prior Estlin, Unitarian minister and master of a successful
school at St. Michael s Hill, is not in the professional list of the 1807 Directory^
but appears in that for 1809, when his residence is given as 2 Unity
Street. Burroughs seems also to have had a branch establishment, for
there is an entry in 1807 of " Yeo and Burroughs, Apothecaries, Granby
House, Hotwells, and Portland Place, Clifton." Jermyn was one of the
Surgeons at St. Peter's Hospital ; Spencer and Smith were two of the three
" Extra Men-Midwifes " of the Dispensary.
On May 15th, 1807, Bowles, one of the surgeons at the Infirmary, died.
On the following morning the Bristol Mirror contained the applications of
ten surgeons for the vacancy, amongst whom were Jermyn, Daniel, Edgell,
Lax, Hetling, and Smith. Apparently only three of the ten persisted in
their candidature, and Hetling was elected with 395 votes, Lowe coming
second with 167, and Smith third with 74. Another vacancy occurred
shortly after, and Lowe was elected in July ; Daniel, Smith, and Edgell
were among the unsuccessful candidates. ■
Digitized by VjOOQIC
224 MR. L. M. GRIFFITHS
The members were to meet at one another's houses once a
month' at half-past six o'clock. When the names were called
over at seven, anyone then absent was to be fined one shilling.
The fine for retaining a book longer than the time allowed was
fixed at threepence each day. At the end of the year the
books out of circulation were to be sold by auction, and any
work not realising more than half its cost was to be taken at
that price by the member who proposed it. It was considered
necessary to insert in the rules that no druggist should be admitted
into the Society, and it was laid down that no one should be
elected a member except by a unanimous vote. One rule stated
that *' Each member shall keep an account of the books received
by him and to whom forwarded, which account shall be regularly
sent to the monthly meetings at or before seven o'clock."
Omission to do this involved a penalty, apparently five shillings
and half a crown at different times. The book in which the
member was supposed to keep this record was afterwards known
as ** his green register," and notes about it frequently occur
in the minutes and rules. 2
The table which accompanies these notes gives the names of
all the members^ during the hundred years, together with the
dates when they became, and when they ceased to be, members,
and also shows the constitution of the Society at each change of
membership. As the minute-book from April 21st, 1813, to
January 20th, 1823, is missing,^ there is some uncertainty about
^ The day has varied from time to time.
'■^ From the beginning of the Society a ledger was to be kept by the
secretary for the entry of all books received, and by whom proposed and to
whom and when .they were sent. With the exception of a few years these
entries are in existence.
3 In a later number of the Journal it may be possible to give some
biographical notes concerning these, and the Editor will be glad to receive
anything of interest in connection with them. It will be fairly easy to
obtain information about some of those who were fortunate enough to die
before the issue of the Dictionary of National Biography, but about many it
will be a matter of great difficulty to present anything like a connected
account.
* It is impossible to say when the volume disappeared. It was not
available in 1886, when the list of members was drawn up for the purpose of
getting portraits of past members.
Digitized by VjOOQIC
ON THE MEDICAL READING SOCIETY, BRISTOL. 225
the dates of that period, and these are printed in italic. They
may be taken as approximately correct, as the cash-book froiri
1817 and some of the fine-lists and sale-lists from 1818 to 1823
are in existence. 1 It will be noticed that only on rare occasions
have the members been less than their full number for more than
a short period. The Society has been so attractive, that men
have often had to wait a long time for admission. There was no
vacancy between 1894 and 1906.
The minute-books do not record much more than the election
and absence of members and the names of the books proposed.
It has been the custom for a long time for the secretary for the
year to close his term of office by giving at the January meeting
a dinner to the members. When this was introduced does not
appear in the minutes.
It would naturally be expected that a society of enthusiasts
such as those forming the Medical Reading Society would procure
the most recent literature concerning any new development
connected with the healing art. On January 20th, 1808, Willan's
hook on Vaccine Inoculation, published in 1806, was ordered.
It was not till February, 1808, that a twelfth member was
proposed. Then Barton 2 was nominated, but at the following
meeting his name was withdrawn, in consequence of a prior
application made by Jermyn on behalf of Sheppard,^ who, however,
was not elected, because at the April meeting, after he had been
twice balloted for, he did not receive a unanimous vote. At the
June meeting, therefore. Barton was again brought forward, but
met with the same fate as Sheppard after the vote had been
twice taken. At the August meeting an acceptable member was
found, when J. C. Swayne* was elected. From November till
this date the Society had practically only ten members, as leave
of absence had been granted to Estlin, who had gone to Edinburgh,
and was away till this meeting.
Further interest in the vaccination question was apparent in
^ The cash-accounts are almost complete, but maay of the fine-lists
and sale-lists are wanting.
^ *' Charles Barton, Surgeon & Apothecary, 3 Hope Square."
3 *' Godwyn and Sheppard, Surgeons. Redcliff Hill."
* " John C. Swayne, Surgeon, &c., 15 Cumberland Street."
16
ToL. XXV. No. 97. ^ J
Digitized by VjOOQIC
226 MR. L. M. GRIFFITHS
;t8o9. At the June meeting Thomas Brown's Inquiry inio the
Anti'Variolous Power of Vaccination (throwing doubts on its
i^fl&cacy) was ordered, and in the following month the Society
unanimously agreed to have (i) The Report on Cow-pock Inocula-
tion from the Practice of the Vaccine-Pock Institution, by Pearson,
Nihell, and Nelson, and any other statement by that Society ;
(2) The Address of the Royal Jennerian Society, instituted 1803 ;
and (3) A Statement of Evidence from Trials by Inoculation of
Variolous and Vaccine Matter by the Physicians of the original
Vaccine-Pock Institution, Established Dec, 1799, ^ printed in 1804.
In January, 1810, the second edition of Bryce on the cow-pock
was ordered. 2
For facilitating the work of the member who had at the end
of the year to compute the fines, an entry was always made of
the absence of the " green register.'* At the meeting at Maurice's
on May 26th, 1810, Estlin appealed against the fine being levied
in his case, as ''his book was on the table from seven to eight
o'clock, and was then removed to another room in the house."
At this period, and for some time afterwards, it was the
custom for the names of both present and absent members to
be entered in the minute-book. For the benefit of the future
historian of the Society, it is much to be wished that this practice
should be restored, as it enables one to see at a glance the com-
position of the Society at any date. On December 21st, 1810,
the cause of Jermyn's absence is stated to be " ill health,'* and on
January i8th, 1811, both he and Spencer are among the absentees.
There is no entry about the withdrawal of either of them, but as
their names do not appear again, it may be taken for granted
that this is about the date of their resignation. Crangs was
elected in February and Baker * in March.
By rule of the Society, each original member paid a sub-
scription of one guinea, and future members were in addition to
pay an entrance fee of one guinea. Although there is no record
^ The Index-Catalogue, vol. xv., 1894, p. 523, has 1779 by mistake.
2 Some notes on the important books ordered by the Society during
the hundred years would be of interest if space permitted.
^ " Crang, James, Surgeon, &c., 17 Queen Square."
^ ** Baker, Robert, Apothecary, 3 St. James's Square."
Digitized by VjOOQIC
ON THE MEDICAL READING SOCIETY, BRISTOL. l227
of it in the minute-book, it would appear that at the beginning
of 1811 the entrance fee was raised to two guineas, for in the
accounts for that year the contributions of Crang and Baker are
entered at three guineas each. At the annual meeting on January
17th, 1812, it was resolved '* that the funds of the Society, after
the payment of last year's accounts, should be equally divided
amongst the respective members." This resulted in the payment
^^ £4 5s. iijd. to each member except Daniel, who, probably in
correction of some error in his previous account, received
£4 13s. iijd. Daniel, who was the proposer of this distribution
of the funds, resigned his membership in March, when Edgell
also withdrew. At the next meeting Smith and Lax left the
Society. It looks as if there was some rift in the lute, for then
only five of the original members were left, and when, at the
meeting in May, Crang withdrew, there had been five resignations
in two months. At this May meeting a Conmiittee, which had
been appointed in the previous month, should have reported
concerning the claims of the Society upon those gentlemen who
had withdrawn, but there is no record in the minutes of their
report, which no doubt was presented, as in the following
December a special note was sent to Crang, who had refused to
pay his fines.
The Society was evidently anxious at this time to have as
members only those who would give it strength, for in May, when
there were five vacancies, the name of William Maurice was
withdrawn on account of his absence from the country. But
Stock ^ and Prichard * were then elected, and at the June meeting
Sheppard, who had failed at the ballot in April, 1808, was received
into the Society ; but although there were two vacancies, the
Society would not have either Porter,^ who had been proposed
in May, or Perry,* who was balloted for in July ; and the same
fate awaited the younger Gold* on January 15th, 1813, on which
1 " Dr. J. E. Stock, 6 Park Street."
' '* Dr. J. C. Prichaxd, Berkeley Square."
' Dr. W. Ogilvie Porter, 29 Portland Square, brother of Jane Porter
who wrote The Scottish Chiefs.
* " Perry, Chas. James, Surgeon and Apothecary, 13 North Street."
" "Gold, Francis, Junr., Apothecary, 7 College Green."
Digitized by VjOOQIC
228 MR. L. M. GRIFFITHS
date the resolution appears affirming the entrance-fee for new
members at two guineas, although Prichard, Stock, and Sheppard
were to be asked to pay only one guinea each, i
When the membership was only ten, the first minute-book
closes with the meeting of April 21st, 1813. After this date
reference should be made to the tabulated list for the dates of the
election and departure of each member.
Whether any members were elected and withdrew during the
ensuing four years it is impossible to say, for the next extant record
of the Society is the statement of accounts for 1817, presented at
the annual meeting on January 20th, 1818. In this are the names
of William Swayne and Gold. The annual subscription was then
half a guinea.
The sale-list of January, 1818, affords the information that
the Society did not limit itself to medical literature, for it contains
The Quarterly Review, The Edinburgh Review, and The British
Review,
Between this date and March, 1823, when it was discontinued,
the newspaper called The Literary Gazette had been ordered, and
also the Westminster Gazette, for which a member held himself
responsible.
When the rules were revised in 1820, the meetings were held
on the third Saturday in every month from half -past six^ till eight
o'clock ; the entrance fee was confirmed at two guineas, and the
subscription was to be the amount necessary to defray the
expenses.
Till 1823 it was a rule that the meetings should be held in
the city ; but on April 17th, when Hetling proposed to receive
the Society either at his own house or at Reeves's Hotel,^ it was
resolved that the meeting should be at his house, 24 Royal York
Crescent, to which he had just moved from 18 Orchard Street ;
and it was further resolved that as Goodeve was a resident in
Clifton, living at 22 Mall, he should not be expected to receive
the Society in Bristol. The distinction between Bristol and
1 When Prichard rejoined the Society in 1832, he paid the entrance-fee
of two guineas.
^ Altered before 1823 to seven o'clock.
» Now the Turkish Baths,
Digitized by VjOOQIC
ON THE MEDICAL READING SOCIETY, BRISTOL. ?29:
Clifton seems to have been up to this time rigidly maintained,
and it was not till the Reform Act came into force in 1832 that
Clifton was added to the parliamentary borough. In 1835 it was
included in the municipal area.
In December, 1823, the Lancet, the first number of which was
dated Sunday, October 5th, 1823, was ordered from the commence-
ment, but in the following February '' it was resolved that the
Lancet is a publication unfit for this Society, and that it be
discontinued.'*
The fine for non-attendance, after having been increased at
some date not discoverable to two shillings for absence during the
whole meeting, was reduced to one shilling in January, 1825 ; and
in the following June the Society re-considered its action in
reference to the Lancet, and ordered it in half-bound volumes,
giving the impression that thus the members would receive less
contamination than by touching the unclean thing in weekly
numbers. In September Howell,' Wilson,* and Nathaniel Smith*
" were balloted for as members, and not received.*'
The two shilling fine for non-attendance at eight o'clock was
restored in January, 1826, when the Society determined to take
the Lancet again in numbers, and also to be responsible for the
Westminster Review.
The dissatisfaction of the Society with the Lancet was again
in evidence in August, 1828, when a proposition was carried that
" This Society, considering the Lancet as a publication injurious
to the respectability and best interests of the profession and dis-
graceful to the medical men who conduct it, resolves that its
circulation in the Society be henceforth discontinued."
In 1829 it was decided to give up the Quarterly, Edinburgh,
and Westminster Reviews.
At the annual meeting in January, 1831, the hour of meeting
was altered to eight instead of seven, and in 1834 the day was
^ Dr. John Howell, living at 45 Royal York Crescent, was one of the
physicians at the Clifton Dispensary, then at i Dowry Square.
^ Wilson's name first appears in the Directory for 1826 in partnership
with Mortimer at 17 Bridge Street.
* He had retired in 18 12, and was evidently seeking re-election.
Digitized by VjOOQIC
236 MR. L. M. GRIFFITHS
changed to the first Wednesday of each month, and it has
remained so till the present time.
At this time it was resolved to take again the Literary Gazette,
which the Society had been without since March, 1823.
An attempt to reintroduce the Lancet failed in January, 1835,
but was successful at the next annual meeting in 1836, when it
was also decided to subscribe for the British and Foreign Quarterly
Review,
A rule that no accumulated fines on a book should exceed one
half of its prime cost was carried in January, 1837, and in the
following year it was decided to abolish the second fine of one
shilling imposed on absentees from the meetings, but at the next
annual meeting it was again restored.
It was unanimously resolved on January 8th, 1840, to dis-
continue the ''Green Register.'* v At the next annual meeting
the Society ordered the Provincial Medical and Surgical Journal,^
but resolved again to give up the Literary Gazette.
Nothing of importance is recorded in the minutes from this
time till January, 1846, when the following propositions were
carried unanimously: (i) That Sunday be a *'dies non;"
(2) That the days of transfer be Monday and Thursday, and that
the period of detaining a book be always three days or a multiple
of three days ; (3) That the Green Register be restored, s It was
also determined once more to give up the Lancet.
In January, 1847, it was resolved "that Mr. Coates [who
had resigned in 1837] ^^ allowed to read the books when out of
circulation upon the payment of one guinea per annum."
In January, 1848, the Lancet seems to have been again taken
on the condition of one member being responsible for it. At the
April meeting we can imagine that a lively discussion took place,
' See p. 224.
^ The precursor of the British Medical Journal.
8 Among the Society's books are Morgan's register from 1846 to the time
he left the Society, in 1872 ; George Hetling's from January, 1846, to
December, 1847, and in the same volume William Cross's from January,
1848, to January, 1870 ; Estlin's from May, 1846, to December, 1854, together •
with that of Hore, who succeeded him, from May, 1855, to December, 1870 ;
Brittan's from May, 1865, to November, 1873.
Digitized by VjOOQIC
ON THE MEDICAL READING SOCIETY, BRISTOL. 23I
for it is recorded that three gentlemen, *' the* 3 minutes after
time by the institution clock, pleaded being in time by their
watches, and it was determined by 5 to 4 that they should not
be fined/'
In the minutes of February, 1849, there is a vague record
concerning " Nathaniel Smith, who was proposed and seconded,"
but there is no note of his rejection, and he was certainly not
elected. As he had failed at the ballot in 1825, this was his second
unsuccessful attempt to re-enter the Society, from which he had
withdrawn in 1812. The vacancy for which he was nominated
was not filled till March, 1850.
In 1854 the Society again took the responsibility of the Lancet,
as the member who had proposed it in 1848 declined any longer
to have it at half-price, but as a member was willing upon that
condition to take the Quarterly Review and the Edinburgh Review,
they were again circulated in the Society.
The Lancet, however, remained in favour with the Society but
a short time, for in April, 1854, it was resolved *' That in the
opinion of the members of this Society the conduct of the Lancet
of late (more especially with reference to the proceedings in the
case of Mr. Gay at the Royal Free Hospital) has not been such as
becomes the Jommal claiming to be the organ of an enlightened
and honorable profession — and therefore, that it be discontinued."
The circumstances were connected with the dismissal of the well-
known surgeon, John Gay, from the Hospital in December, 1853.
This caused much indignation among many members of the
profession, and a meeting 1 — at which it was suggested that
Thomas Henry Wakley, son of the editor of the Lancet, and who
was one of the surgeons at the Hospital, had had something to
do with it — was held on January i8th, 1854, to protest against
the action of the committee of the Hospital. The pages of the ,
Lancet for the first half of 1854 ^.re amply provided with very
strong language on this subject.
^ The secretary of the organisation of this meeting was Harvey Ludlow,
brother of Ebenezer Ludlow, successively Resident Medical Officer and
first Assistant-Physician at the Bristol Royal Infirmary. The Royal Medical
and Chirurgical Society, at its meeting on March ist, 1854, also decided to
withdraw the Lancet from its list.
Digitized by VjOOQIC
232 MR. L. M. GRIFFITHS
On January loth, 1855, there is a note that '* Mr. Swetei was
unanimously elected an honorary member as successor to Mr.
Coates.'*2 No reason is stated for the choice of Mr. Swete, who had
never been in the Society. There is nothing in the revised rules
of 1820 or in the 1877 edition about honorary members; but
a resolution may have been passed between 1820 and 1823 in
reference to them, and this may have been in evidence at the
time, although the minute-book for that period has been lost.
Coates had resigned in 1837 after a membership of less than five
years, and there is no record why the special privilege had been
conferred upon him. At this January, 1855, meeting Estlin, who
had been in the Society more than forty-seven years, resigned,
and he was very properly made an honorary member. « Upon
this occasion the sins of the Lancet had been partly condoned,
and only eight months after the emphatic resolution condemning
it, it was again ordered for the Society, but only on the under-
taking of a member to purchase it at the sale at half-price.
At the October meeting in 1855, the Society, having to choose
between William Budd and Sawer, elected the former.
The annual meeting in January, 1856, decided that the Society
should take the Lancet.
A proposal that the Society should no longer circulate the
Quarterly Review and the Edinburgh Revieiv failed in January,
1857, to find a seconder ; and at the next annual meeting the
AthencBum was added to the list on the same terms as the Reviews
were taken in 1854, but it remained only for twelve months. The
same member who had proposed the discontinuance of the
Reviews failed again in 1857 ^^ secure it. In March it was resolved
\} "E. H. Swete, surgeon, i Dowry Parade," the author of Flora
Bristoliensis, 1854, on the title-page of which he is described as "Lecturer
on Botany at the Bristol Medical School." A search through the minute-
books of the School has failed to discover any entry made about him.]
2 The title of honorary member was a misnomer, as Coates was required
to pay an annual subscription (see p. 230). The resolution of January, 1847,
gave him no distinctive title. Mr. Swete paid a guinea a year for two years.
' Smerdon, who had been " acting secretary " for thirty years, was
made an honorary member upon his resignation on account of illness in 1870.
Crosby Leonard was elected an honorary member in July, 1879, after a
membership of nearly twenty years, but he lived to enjoy the honour only^a
few months.
Digitized by VjOOQIC
ON THE MEDICAL READING SOCIETY. BRISTOL. 233
" that Mr. Goodeve be an associate of the Society,*' on the under-
standing that he " should be liable for an annual subscription, but
not for fines ; " but the minutes afford no information as to the
reason of this step, which was no doubt taken on account of his
long membership.! Probably the connection by associateship,
for which there seems no provision in the rules, was a merely
nominal one, although, as he was not to be fined, it would appear
that he was to receive the books, perhaps after they had gone the
round of the members.
The Society declined in January, i860, to add Bentley's
Quarterly Review^ to the list, and in 1861 it decided to give up
the Quarterly Review and Edinburgh Review, which, however,
were restored in 1864.
A new departure is chronicled in July, 1864, when a sub-
committee was appointed '* to make arrangements for the
excursion," and in June, 1865, two members were requested " to
arrange for the annual expedition." A member of the Society
at the time recollects going to Aust, where they dined and
geologised, but no information is forthcoming in reference to
the other outing, and probably there were only these two.
The desire for high-class periodical literature other than
medical was frequently manifested, and in January, 1869, the
Revue des Deux Mondes was ordered, but remained on the list
only till January, 1870, when with the Quarterly Review and the
Edinburgh Revieiv it was discontinued.
Social changes made it desirable to alter the hour for meeting,
and in January, 1871, it was decided to make this nine o'clock
instead of eight, and at that hour it has since remained. And on
December 4th, 1872, it was agreed that the annual meeting should
be held in December instead of January, thus giving more oppor-
tunity for the transaction of business than on the evening of the
dinner. In the revised rules, which were issued in 1877, the
January meeting is called the annual meeting, but in November,
1878, the resolution of December 4th, 1872, was re-adopted.
In January, 1881, the rule referring to the fine-committee
^ Goodeve had resigned in the previous August after having been a
member for 38 years.
■-* This died after its secoijid volume.
Digitized by VjOOQIC
234 MR. L. Mv GRIFFITHS
was elaborated with much detail, and in 1882 some minor altera-
tions about the election of secretary were adopted.
In order to facilitate the ordering of books, it was agreed in
1883 tcr take in the Bookseller, a monthly trade- journal giving
classified lists of new pubhcations, and it was resolved that the
secretary should produce it at each meeting ; but this useful
periodical seems to have been in favour for only one year.
In 1884 the Society decided to make an effort to procure the
portraits of all past members. This has succeeded to some extent,
and they are preserved in albums among the archives of the Society.^
Greig Smith, at his secretarial dinner in 1885, embellished the
menu card with some lines of verse. 2
In 1891 the Library of the Bristol Medico-Chirurgical Society
was opened in the Literary and Philosophic Club, and was moved
to the Medical Department of University College in 1893. The
Reading Society, at its meeting in January, 1902, nobly gave all
its periodicals to the library, but in 1904 they ** were presented
to those members wishing to have them.*'
At the meeting on March 7th, 1907, '* it was unanimously
* The following have not yet been obtained, and the Society would be
grateful for any help in securing them.
Jermyn Gold Stock Mortimer
B. Spencer J. Maurice Bernard Goodeve
Daniel Gilby W. Maurice Hore
Edgell Sheppard Howell Ring
Lax Baker King
Arrangements would be made for photographing any portraits that may
be lent for the purpose.
2 ESTO MIHI, ERO TIBI.
Twelve Medicos of high renown, Let Hansnt peep into your ear.
In this our ancient Western Town, From hidden holes your germs to ferret
Harmoniously combine There 's none so 'cute as Mtrkham Sk«rritt :
To take in books for culture's sake. His microscope will soon determine
Meet once a month for tea and cake, How Shlngleton will kill the vermin :
And once a year to dine. And livers weary of their life
These twelve, of varied reputation. Find comfort in the arms of j^ffe.
Are competent to treat a nation With Grlfflthf strong on vaccination
For, be your ailment what you please. And apt Shakespearian quotation,
There 's one at least for your disease. With Lansdown for our angiomas.
Of eyesight should you threaten loss. And Dobton for round-celled sarcomas.
The man to make you see is Croff ; We need not fear : but if more ill,
And should your reason show a flaw, There 's Beddoe and there 's Priehird still.
The man to lock you up is Shaw ; Should these eleven "fall to mend you,
And if you think you cannot hear, Then GreIg Smith*! knife will gently end you.
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J
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MEMBERS
AND THEIR SECRETARIAL YEARS.
Mr. THOMAS JERMTN (1807)
1 Mr. HENRT DANIEL (1809)
Mr. RICHARD EDGELL (1811)
Mr. BENJAMIN SPENCER
Mr. WILLIAM MORTIMER (1818, 1835)
Mr. ROBERT LAX (1808)
Mr. BENJAMIN GUSTAVUS BURROUGHS .. {1814)
Mr. JOSEPH MAURICE (1815)
2 Mr. WILLIAM HETLING (1812,1817,1832)
3 Mr. NATHANIEL SMITH (1810)
4 Mr. JOHN BISHOP ESTLIN (1816, 1838)
5 Mr. JOHN CHAMPENT SWATNE . . . . (1820, 1837)
Mr. JAMES CRANG
Mr. ROBERT BAKER (1813)
6 Dr. JAMES COWLES PRICHARD . . . . (1819, 1833)
7 Dr. JOHN EDMONDS STOCK 1821)
Mr. EDWARD W. SHEPPARD {1822)
8 Mr. FRANCIS GOLD
9 Mr. WILLIAM SWATNE (1823)
Dr. WILLIAM GILBT
Mr. WILLIAM MAURICE (1824)
xo Mr. WILLIAM JAMES GOODEVE . . (1825, 1842. 1850)
Mr. ISAAC LEONARD (1826, 1843, 1855)
Mr. JOHN KING (1827)
11 Mr. WILLIAM FREDERICK MORGAN (1828, 1847, 1863)
Dr. CHARLES EDWARD BERNARD . . . . (1829)
Mr. JOHN GRANT WILSON (1830)
Mr. JOHN HARRISON (1831)
Mr. WILLIAM COATES (1834)
Mr. CHARLES SMERDON . . . . (1836. 1853, 1867)
Dr. JOHN HOWELL
12 Mr. GEORGE HILHOUSE HETLING .. .. (1839)
13 Mr. WILLIAM BENJAMIN CARPENTER . . (1840)
Dr. ALEXANDER FAIRBROTHER . .(1841, 1851, 1868)
14 Mr. JOHN COLTHURST (1844)
15 Mr. AUGUSTIN PRICHARD (1845, 1864)
i6 Mr. JOSEPH GRIFFITHS SWATNE . . . . (1846)
17 Mr. ROBERT WILLIAM COE (1848, 1852)
Mr. WILLIAM CROSS (1849, 1865)
Mr. EDWARD WALDO (1851)
Mr. HENRT AUGUSTUS HORE . . . . (1856, 1869)
iS Dr. WILLIAM BUDD (1857)
19 Mr. THOMAS GREEN (1858,1873)
Dr. HENRY EDWARD FRIPP (1859)
20 Dr. EDWARD LONG FOX (1860)
Dr. JOHN BEDDOE (1861)
21 Mr. CROSBY LEONARD (1862)
22 Dr. FREDERICK BRITTAN (1866)
23 Mr. ROBERT WILLIAM TIBBITS (1870)
Mr. EDMUND COMER BOARD (1871)
24 Mr. THOMAS EDWARD CLARK (1872)
Dr. WILLIAM HENRY SPENCER (1874)
Dr. ROBERT SHINGLETON SMITH . . (1875, 1890)
Mr. NELSON CONGREVE DOBSON.. .. (1876,1891)
Mr. FRANCIS POOLE LANSDOWN (1877)
Mr. LEMUEL MATTHEWS GRIFFITHS.. .. (1878)
25 Dr. EDWARD MARKHAM SKERRITT . . (1879, 1898)
Mr. CHARLES GORE RING (1880)
Dr. JOHN EDWARD SHAW (1881, 1899)
26 Dr. WILLIAM JOHNSTONE FTFFE . . . . (1882)
Mr. FRANCIS RICHARDSON CROSS .. .. (1883)
27 Mr. JAMES GREIG SMITH (1884)
Mr. WILLIAM HENRY HARSANT . . . . (1885, 1900)
Dr. ARTHUR BANCKS PROWSE (1886)
Mr. CHARLES FREDERICK PICKERING . . (1887)
Mr. ARTHUR WILLIAM PRICHARD .. (1888,1901)
Dr. JOHN MI CHELL CLARKE .. .. (1889,1902)
Mr. JAMES PAUL BUSH (1892, 1908)
Mr. JOHN DACRE (1893, 1904)
Dr. PATRICK WATSON WILLIAMS
Dr. GEORGE PARKER (1894, 1905)
Dr. JAMES SWAIN (1895, 1906)
Dr. ROBERT GUTHRIE POOLE LANSDOWN (1896)
Dr. BERTRAM MITFORD HERON ROGERS.. (1897)
Mr. JAMES TAYLOR (1907)
Mr. GEORGE MUNRO SMITH
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I See Bristol M.-Chir. /., 1890, viii. 186-7.
2 See Bristol M.-Chir. /., 1890, viii. 182-3 1 1892, x. 268.
3 See Bristol M.-Chir. J., 1890, viii. 187-8.
4 See Did. Nat. Biog. and Augustin Prichard's A Few Medical and Surgical Reminiscences,
1896, pp. 10 — 14.
5 See Bristol M.-Chir. /., 1892, x. 269 — 70, 289 — 90.
6 Resigned in 1825, but was re-elected in 1832. See Diet. Nat. Biog. ; Bristol M.-Chir. /., 1890,
viii. 176-8 ; 1892, X. 265 ; Augustin Prichard's A Few Medical and Surgical Reminiscences,
1896, pp. 14 — 16, 25
7 See Bristol M.-Chir. /., 1890, viii. 172-4.
8 See Latimer's Annals of Bristol in tiie Eighteenth Century, 1893, p. 524.
9 See Bristol M.-Chir. J., 1890, viii. 169 — 70.
10 See Latimer's Annals of Bristol in the Eighteenth Century, 1893, p. 524.
11 See Bristol M.-Chir. /., 1890.. viii. 170.
12 See Bristol M.-Chir. J., 1890, viii. 183-4 I 1892, x. 272.
13 Became M.D. in 1839. See Diet. Nat. Biog. and Augustin Prichard's A Few Medical and
Surgical Reminiscences, 1896, pp. 30-2.
14 See Bristol M.-Chir. J., 1892, x. 272.
15 Sct\)^s Few Medical and Surgical Reminiscences, 1896, and Some Incidents in General Practice,
1898 ; Bristol M.-Chir. /., 1892, x. 272 ; 1898, xvi. i — 15.
16 Became M.D. soon aifter joining. See Bristol M.-Chir. J., 1892, x. 272 ; 1903, xxi. 193 — 202.
17 Resigned in 1848, upon leaving England, but was re-admitted in 1850. [The end of the
secretarial work for 1848 was taken by Hetling. See Bristol M.-Chir. J., 1892, x. 273.
18 See Diet. Nat. Biog. ; Bristol Royal Inf. Reports, 1878—79, i. 361-7 ; Bristol M.-Chir. J., 1892,
X. 273.
19 See Bristol M.-Chir. /., 1892, x. 272.
20 See Bristol M.-Chir. J., 1892, x. 273 ; 1902, xx. 97 — 105.
21 See BristolRoyal Inf. Reports, 1878 — 79, i. 210 — 25, 342 — 60 ; Bristol M.-Chir. J., 1892, x. 273.
22 See Bristol M.-Chir. /., 1891, ix. 67 — 70 : 1892, x. 273.
23 See Bristol Royal Inf. Reports, 1878—79, i. 226 — 31.
24 Became M.D. in 1872. See Bristol M.-Chir. J., 1892, x. 287.
25 Died April 29th, 1907. See Bristol M.-Chir. J., 1907, xxv. 97 — 108.
26 See Bristol M.-Chir. J., 1901, xix. 97 — 100.
27 See Bristol M.-Chir. /., 1897, xv. 105—21.
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ON THE MEDICAL READING SOCIETY, BRISTOL. 235
carried that to celebrate the centenary of the Society, a dinner
should be held on the day of meeting nearest to the date of in-
auguration of the Society,'* and that past members be invited as
guests of the Society. In accordance with this resolution the
twelve members of the Society and six former members dined
together at the Clifton Club on April srd.i
Although the limited information afforded by the records has
made it impossible to provide anything like an adequate history
of the Society, it would be wrong to close this fragmentary account
without giving a full meed of praise to it for the indirect benefit
which it has conferred upon the local profession, whose
indebtedness to it should be distinctly recognised. During the
long period of a hundred years a small Society, numbering many
scholarly and prominent men, has shown the necessity, in keeping
abreast of the times, of having constantly before it the best
literature obtainable ; and its continuance is evidence that the
needs of an enlightened profession are not entirely met by the
provision of an excellent reference library, such as local medical
practitioners have at their command, but that it is essential that
there should be the means of consulting desirable books and
periodicals at more leisure than is possible with a library which
is not a lending one.
The Society, now so strongly representative of all that is best
and highest in the profession, and with a century's good work as
its voucher, could, by taking the initiative in the founding of a
medical institute or club that would bring together practitioners
in closer professional and social relationship, add to the usefulness
which hitherto it has been able to achieve. Such an institution
should elicit the practical sympathy and hearty co-operation of the
local profession, members of which should see in it an opportunity
for mutual help and encouragement in their difficulties and
disappointments; and the Society would have the privilege of
extending, in an ever - widening circle, the purpose of ** pro
moting medical knowledge and friendly intercourse," which its
originators set before themselves as their object, and which suc-
ceeding generations have so well and so honourably maintained.
* A photograph of the occasion is preserved in the minute-book.
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IProdrcdd of tbc JfDeNcal Sciences*
MEDICINE.
For this summary of the pathogenic streptocoeei we are in-
debted to Dr. I. Walker Hall, Professor of Pathology, University
College, Bristol, and Pathologist to the Bristol Royal Infirmary.
It has always been difficult to satisfactorily classify palhogenic
streptococci. Morphological characters, such as the size of the
cocci and the length of their chains, are insuf&cient. The several
staining reactions are not precise enough for accurate differential
diagnosis. Apart from broth, the ordinary culture media do not
yield information which permits useful deductions. Even the
pathogenicity of the organisms may render but little help, since
their virulence is easily lost during cultural or other methods, or
altered, or raised, by passage through susceptible, or non-suscep-
tible, animals. Serum reactions have also failed to distinguish
distinctly between the various types, a fact which will be well
appreciated by those who have used anti-streptococcus serum.
An investigation made, however, by Mervyn Gordon i upon
the chemical powers, or metabolic reactions, of streptococci, has
opened up a new field of much promise. As a result of a number
of tests of the action of streptococci on various substances, he
has found that the following may be employed for diagnostic
purposes : —
Two dissaccharides : saccharose and lactose.
One trisaccharide : raffinose.
One polysaccharide : inulin.
Two glucosides : salicin and coniferin.
One alcohol : mannite.
These, together with the clotting of milk, and the reduction
of neutral red under anaerobic conditions, constitute a series of
tests which point to the type of organism involved. They are
not infallible, and the individual organisms exhibit considerable
variations, but they permit conclusions within certain limits.
Staphylococci also may be differentiated by other tests of a
similar nature, but the same precautions must be observed in
making the deductions. No hard and fast line is permissible.
From a correlation of all the available records (about 1,200
strains) Andrewes and Horder^ propose the following classifica-
tion. Each type may be divided into a nimiber of sub-types or
variants : —
1 Gordon, *' Report to Local Government Board," 1906.
3 Andrewes and Horder, Lancet, 1907, i. 167.
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3IEDICINE.
237
1. Streptococcus equinus, derived chiefly from air, dust,
horse-dung, &c. Generally non-pathogenic.
2. Streptococcus mitis. Found in human saliva and faeces.
Occasionally pathogenic.
3. Streptococcus pyogenes. Pathogenic.
4. Streptococcus salivarius. Occurs in saliva and intestine.
Pathogenic.
5. Streptococcus anginosus. Isolated from *' sore throats."
Pathogenic.
6. Streptococcus fsBcalis. Occasionally pathogenic.
7. Pneumococci. Pathogenic.
The reactions of these organisms are stated in the following
table (Andrewes and Horder, ix.) : —
Types.
i
1
i
i
Morphology.
u
iz;
3
3
.y
i
a
5
Streptcxjoccus pyogenes
+
+
±
+
Longus.
salivarius
+
±
+
+
±
...
±
Brevis.
„ anginosus
+
±
+
+
...
...
...
±
Longus.
iaecalis
+
+
+
+
...
+
+
+
+
Brevis.
Pneumococcus . .
±
+
+
+
±
••
...
...
Brevis.
It is of interest to consider the relation of diseased processes
to the particular type of streptococcus. The following figures
are taken from the papers available : —
1. Suppuration.
Streptococcus pyogenes 30 cases.
sahvarius 5 „
„ anginosus 8 „
„ faecalis 2 „
Pneumococcus 19 „
2. Cystitis.
Streptococcus faecalis 2 cases.
„ (variants) .... 2 „
„ salivarius 2 ,,
Sometimes the streptococci were present alone, some-
times they were associated with B. Coli. It is quite
evident that the organisms were intestinal in origin.
The streptococcus pyogenes has not been met with in
this condition.
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238 PROGRESS OF THE MEDICAL SCIENCES.
3. Erysipelas and Cellulitis.
Streptococcus pyogenes alone. No other forms.
4. Serous Effusioiis.
Streptococcus pyogenes 3 cases.
„ anginosus i case.
5. Non-suppurative peritonitis.
Streptococcus pyogenes (variants) . • , , 4 cases,
salivarius 3 „
6. SeptiesBmia.
(a) Puerperal,
Streptococcus pyogenes always.
[h) Following primary streptococcal infection.
Streptococcus pyogenes and variants 13 cases.
salivarius i case.
,, anginosus i „
„ faecalis 2 cases.
Pneumococcus 7
(c) Following infections not primarily streptococcal.
Streptococcus pyogenes 7 cases.
salivarius 5
Pneumococcus 2 „
7. Malignant Endocarditis.
Streptococcus pyogenes 2 cases.
„ salivarius 11 „
anginosus 6 „
,, faecalis 4 „
Pneumococcus i case.
The preponderance of intestinal and faecal organisms in this
condition is very striking, and suggests that in these patients
the low virulence of the organisms may account for the defective
" resistance."
In scarlet fever the results so far are not sufficiently decisive.
In acute rheumatism the organisms isolated appear to give
the same reactions as the streptococcus faecalis. Of course this,
or another organism, may be etiologically connected with the
disease, but it first must be proved that the organisms already
isolated have not been those of ** terminal '* rather than " causa-
tive *' infections.
The importance of these results will be appreciated in con-
nection with treatment. It is obvious that the organism must
not only be isolated from the lesion, but must be run to earth.
Its precise identification is most valuable for prognosis and
treatment.
If the indications are for serum treatment, then it is evident
that in a serum prepared from organisms similar in iyipo. to those
isolated from the lesion lies the hope for success.
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...,., .. -MEDICINE,^ ...... ... . 239
Should it be necessary to prepare a vaccine from the isolated
organism, then the dose will be regulated by a knowledge of the
average virulence of the particular type it belongs to.
Investigations which are now in progress point to similar
developments with regard to the several types of staphylococci.
Pernieious AnsBmiaJ — ^The chief points of interest brought out
in the discussion on pernicious anaemia are the need for a more
systematic classification of the disease, and the necessity for
reviewing the condition from the standpoint of the total volume
of the blood and its total quantity of haemoglobin. It has been
for some time evident that an extended knowledge of the aetiolo-^
gical factors concerned is absolutely necessary. The attention
has been focussed on blood films and blood changes quite long^
enough ; abnormal intestinal processes have been boomed
perseveringly without being sufficiently identified ; the ex-
perimental pathologist must now take up the work. The dis-
cussion was opened by Hunter, who at once emphasised the
differences between Addison's idiopathic anaemia and Biermer's
progressive pernicious anaemia. The latter condition includes a
number of different forms of anaemia, while the former is an
infective haemolytic anaemia which is precise in type and distinct
in its symptoms. The blood changes in Addison's anaemia are
those resulting from haemolysis and the subsequent regeneration
of the broken-down elements. Hence we hear of normoblasts
and megaloblasts, as well as of microcytes and macrocytes, far too
much being made of the megaloblastic appearances. In addition,
the leucocytes are increased, this feature being most marked in
the bone marrow, where coarsely granular myelocytes are very
abundant. Both the blood and the bone marrow changes, how-
ever, vary in extent and in their relations to each oth^sr. So far
as we at present know, it is impossible to place any definite
reliance upon these factors. Among the infective lesions, atten-
tion is directed to an exudative, or proliferative,, glossitis. To the
naked eye the tongue is dry, and generally presents one or more
darkly-tinged areas. Certain gastric and intestinal lesions also
occur, and post-mortem exhibit the appearances of localised de-
generative inflammation of the mucosa, and proliferative inflam-
mation of the submucosa.
Discussing the causation of pernicious anaemia. Hunter ob-
served that the ordinary causes of anaemia were insufficient to
produce the whole features of the disease. Infection and injection
with specific haemolytic agents alone explained the usual symp-
toms ; the importance of this conception was realised when
antiseptic treatment was adopted as a routine measure.
^ Impressions of a discussion at the Annual Meeting of the British Medical
Association, 1907.
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240 PROGRESS OF THE MEDICAL SCIENCES.
In some cases Hunter demonstrated the presence of strepto-
cocci in the tissues, and this indication for serum treatment was
followed with success ; but whether he was dealing with a
primary coccal infection, or a secondary invasion of the organism
in debilitated tissues, was not quite clear.
GuUand pointed out that prolonged blood destruction does
not give rise to pernicious anaemia, for the condition precedes the
active haemolytic stage, and thus the toxin may interfere with
the formation of the blood elements rather than promote their
destruction. There may even be a " predisposition " on the
part of some individuals to this action on the formation processes.
Leucopenia is often a distinct feature, while the increased number
of myelocytes in the bone marrow is a well-known fact. He then
compared the appearance of megaloblasts in pernicious anaemia
with the constant presence of megaloblasts in the early embryonic
life of mammals, and suggested that the increase in the red marrow
in pernicious anaemia may arise from a slow formation of megalo-
blastic tissue, or that, when formed, the life of the tissue may be
a short one only.
Lorrain Smith suggested that more attention should be paid
to the changes in the spinal cord. Those at present known consist
chiefly of advanced sclerosis of various tracts (the segments
corresponding to the abdominal area). Much might be learned
from an examination of an early case. He also drew attention
to the '* simulating " forms of anaemia. Malaria is sometimes
accompanied by an anaemia of a ** pernicious anaemia '* type, as
well as a secondary anaemia. An ulcerating fibroma of the
intestine was accompanied by the signs of pernicious anaemia,
and malignant growths are frequently associated with a similar
condition.
A most valuable means of determining the extent of the
haemolysis is afforded by the estimation of the total volume of
the blood, and its total haemoglobin contents, by the Haldane-
Lorrain Smith method. In fact, it is a question whether the
ordinary methods of haemoglobin estimation throw any real light
on the situation. Lorrain Smith examined seven cases of per-
nicious anaemia, and found that the total amount of haemoglobin
was only 50 per cent, of the normal (in chlorosis it reaches 75 per
cent, of the normal, and after the hemorrhage of gastric ulcer
there is only 15 per cent, loss from the normal amount). The
amount of blood plasma is also an important factor, for oedema of
the tissues is a constant feature in pernicious anaemia. The
volume of the blood is often 60 per cent, above the normal ; a
reduction to the normal is a favourable symptom. The fall in
the volume is generally accompanied by an increase in the per-
centage increase of haemoglobin. This alteration in the volume
may be regarded as a distinct effect of the toxin.
Muir observed that the toxin evidently possessed independent
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MEDICINE. 241
characteristics, for although bothriocephalus latus and saponin
acted on the tissues so as to induce megaloblastic changes, yet
they did not entirely reproduce the appearances of pernicious
anaemia. The bone-marrow changes should, however, be regarded
as the expression of an injury rather than of a reaction, and of
an injury which might be recovered from.
Hutchison recorded the fact that he had never met with a
case of pernicious anaemia in children. This is of importance
in connection with the aetiology of the disease. The marrow
and blood-forming organs of the child are generally working at
high pressure in order to meet the needs of the growing tissues,
and it is easy to suppose that they might exhibit some tendencies
to pernicious anaemia. But this is not the case. The only con-
ditions in the child at all comparable to pernicious anaemia are
perhaps those of the acute purpuric conditions of childhood.
How can this difference between youthful and adult tissues be
explained ?
Melland described several cases which presented the charac-
teristic microscopic features of pernicious anaemia without any
glossitic, gastric or intestinal symptoms.
Walker Hall stated that the general nutrition in pernicious
anaemia shows wide variations. The extent of the variations
exceeded the individual factor, and suggested that in the *' sjnnp-
tom complex,'* termed pernicious anaemia, we are dealing. with
the actions of different types of toxins. He emphasised the need
for systematic classification. In detailing the abnormal changes
of metabolism, he pointed out that protein retention was a common
feature, and that the manner of the protein decomposition sug-
gested renal changes, which deserved recognition during treat-
ment. The cells became exhausted and fatty because of the
stress of work in obtaining the necessary amount of oxygen from
the diluted plasma. The output of amino acids and of lactic acid
required investigation by the newer methods.
The secretion of hydrochloric acid is affected. Subacidity, or
absence of hydrochloric, frequently occurs. The gastric secretion
exhibits close relationships with the anaemia, being increased or
diminished as the anaemia improves or changes for the worse.
The distribution of iron in pernicious anaemia varies con-
siderably. Sometimes met with in the liver, at other times it
may occur in both liver and kidney, or in the kidney alone.
These peculiarities are difficult to explain.
A few cases which presented all the clinical appearances of
pernicious anaemia revealed at the autopsies a number of isolated
tubercles in the mesentery, or in the mesentery and liver.
Boycott dealt with the anaemias associated with animal
parasites. He pointed out that the two distinct species of
ankylostoma duodenale produced identical symptoms of disease,
although their geographical distribution was so different. The
17
"Vol. XXV. No. 97.
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242 PROGRESS OF THE MEDICAL SCIENCES.
fact that the subjects of '* parasitic " anaemia suffer more from
the anaemia itself than from the position of the parasite in the
tissues, suggests that similar conditions might obtain in the other
anaemias. It is remarkable that patients with ankylostomatous
anaemia possess much more physical energy than those with
pernicious anaemia when the haemoglobin percentages are about
the same ; in other words, the loss of haemoglobin is felt less by
the ankylostomatous, than by the pernicious, anaemia patient.
Ferguson made a similar statement with regard to the Egyptian
fellah, who will do a hard day's work when the haemoglobin and
red blood count are exceptionally low. f^^ ^"^
Boycott found that in ankylostomatous anaemia the total
volume of the blood was increased by loo per cent., although there
was no diminution in the total amount of haemoglobin. ' He
suggested that the decreased quantity of haemoglobin per cor-
puscle may compensate for the increased volume of the blood,
so as to enable the necessary oxygenation. During recovery the
number of red cells is increased beyond the normal. The pathology
of the condition is not distinctly related either to haemolysis or
to hemorrhage ; it must be attributed to some alteration of the
balance between the in- and outside of the vascular paths.
Ferguson drew attention to the extensive loss of blood from
the large number of bites upon the intestinal mucosa. He con-
sidered that a large proportion of the bitten areas became septic,
and that the products of the sepsis were responsible for some of
the symptoms.
Gulland related two cases suggestive of alimentary tract infec-
tion which were decidedly improved by the continued administra-
tion of fresh uncooked bone marrow. The marrow was obtained
from the shin bone of the ox, and one ounce, or more, spread
upon thin slices of bread was given three times a day. At
first the raw marrow may occasion retching, but this sensation
disappears after a few doses. Gulland suggests that the action of
the bone marrow is to neutralise the active toxic agents, and that
in pernicious anaemia the bone marrow is deficient in this regard,
and so succumbs to the presence of the toxin.
The sum total of the discussion does not indicate any new
forms of treatment, although it points to a number of problems
for investigation, and emphasises the great loss to the community
when a case of pernicious anaemia is allowed to pass through our
hands without sufficient record of the observations demanded.
To listen to a discussion of this kind is a depressing experience.
The needs for investigation are fully evident ; the objects to be
aimed at are outlined clearly ; the possible results are fraught
with enormous benefits to the public ; yet the slow progress
towards fuller knowledge is appalling. The work needs special
training in methods of technique, unlimited time for observation
and reflection, and financial assistance to adequately maintain
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SURGERY, 243
those men — and their number should be a large one — ^who elect
to devote their lives to this end. The blanks in our English
system of education are perhaps most fully illustrated when the
scholar becomes a wage-earner, an elector, or an elected repre-
sentative ; for it is our savage consideration for the care of swine
and other animals, rather than that of children, or human adults,
which permits the scorn of neighbouring nations and allies;
they concern themselves with the care of the pig only so far as
its presence or consumption affects the health of the people, but
consider it a national duty to promote and finance every possible
effort towards the prevention of human disease. For tangible
hospital buildings, preferably new ones, for elaborate municipal
decorations, for additional libraries and displays of arts, the
present generation expends its energies. Would that some men
followed, or even surpassed, the example of American and German
citizens in their provision for the improved health of the nation 1
The man of foresight must surely recognise that the national
physique is the first line of defence of our country, and that if we
are to retain our monumental buildings and our prestige, the
present racial degeneration and ill-health must be stopped. In
plain words, this means financial support for investigation, and
the profession must speak with definite and emphatic voice on
this point. The public will respond when we honestly state our
case, and logically set forth its requirements. Then when workers
are numerous, and Institutes for the investigation of disease are
provided, the nation as a whole will become keen upon scientific
medicine, and it will not be necessary to deplore the slow progress
towards the solution of the problem of this grave anaemia, which
at present resists the applications of our limited knowledge.
I. Walker Hall.
SURGERY.
There have been few surgical advances within recent years to
compare, in their practical impor,tance, with those made in the
treatment of general peritonitis. A few years ago it was very
exceptional for any patient to recover after a widely-diffused
suppurative peritonitis ; but the conditions are different nowa-
days, and by the application of modern methods of treatment a
large proportion of patients may be saved, even in cases in which
there is widely-generalised peritoneal inflammation. The two
most important advances in treatment are those generally known
in association with the names of Drs. Fowler and Murphy ; and
although they have only been in use the last few years, they
have become recognised as standard methods. The Fowler
position consists in placing the patient in the upright sitting
posture as soon as possible at the time of, or immediately after,
operation ; so that the peritoneal exudation may gravitate to
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244 PROGRESS OF THE MEDICAL SCIENCES.
the lower abdomen, where drainage is provided for, away from
the more dangerous diaphragmatic region. Dr. Murphy explained
his methods before the American Medical Association in 1904.
The principles are : (i) Rapid removal of the focus, and closure
of the h le in the gut, with as little disturbance of the peritoneum
as possible ; (2) Drainage through the cperation-wound and above
the pubes ; (3) Rapid procedure, preferably through the rectus,
and without the insertion of sutures ; (4) Food is withheld from
the mouth for two or three days ; (5) Continuous saline injections
are given by the rectum. Thes3 are administered from an
irrigator, placed from four to six inches above the level of the
anus by means of tubing and a short nozzle having lateral open-
ings.%Thus from twelve to twenty pints may, under favourable
conditions, be absorbed ; -and not only is the thirst relieved
thereby, but the tongue becomes moist, there is an increase of
the urinary and peritoneal flow, and the heart and kidneys are
stimulated. The idea is that, by the continuous injection of
saline, the direction of osmosis is reversed, and there is accordingly
a free flow of peritoneal exudate through the wound.
Although these measures are generally recognised and acted
upon, there are minor variations in detail employed by different
surgeons, which it may be instructive to survey. In a paper read
by Le Conte before the Philadelphia Academy of Surgery 1 and
subsequently discussed, we have the following views. The chief
factors in abdominal drainage through a pelvic tube are the effect
of gravity and the pump-like action of the diaphragm. The
rectal irrigation causes such an increase of peritoneal flow that
the dressings become readily soaked, and there is an increase in
the amount of urine passed. Dr. Gibbon had employed the
Fowler position and Murphy treatment with success, but he had
not been able to get his patients to absorb so much saline fluid
as mentioned. Dr. Harte was convinced of the importance of
keeping food away from patients after operation, thus materially
diminishing the tendency to distension. The question of drainage
was more especially considered in a paper read by Knott 2 before
the Chicago Surgical Society and subsequently discussed, and in
some respects his method presents some differences. He believes
that free drainage of the infected peritoneum is the essential
factor in successful treatment, and supports his argument by a
record of seventeen recoveries out of nineteen cases, the fatal
cases comprising one originating from the appendix, and the other
from a large ruptured suppurating ovarian cyst. He thinks that
the abdominal incision should always be ample, and made in the
middle line either above or below the umbilicus, as the case may
be. This is followed by immediate and thorough repair of the
diseased parts. Then an incision is made just above the sym-
physis, and through this a large rubber tube at least one inch in
1 Ann. Surg,, 1906, i. 231, 314. ^ Jbid., 1905, ii. 75, 316.
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SURGERY. 245
diameter, previously split from end to end and carrying a gauze
wick, is passed to the bottom of the pelvis. Abdomino-vaginal
drainage may be similarly arranged for, using a rubber tube with-
out gauze. The abdominal cavity is then thoroughly washed out
with gallons of hot salt solution, care being taken to reach all the
fossae and concealed septic areas. The upper incision is then
rapidly closed, but before tying the last stitch the abdomen is
filled with salt solution by means of a funnel. The lower wound
is left open, and in males an additional tube, similar to the first
but without the wick, is introduced to the bottom of the pelvis
alongside the first. The patient is then raised to the sitting
posture while yet on the table, and this position is maintained
during removal and subsequently when in bed. The dressings
require frequent renewal, and when the flow becomes more scanty
the fluid is pumped out through the plain tube every two hours
for the next twenty-four hours. All tubes may be withdrawn in
from five to eight days. He makes the incision a long one, and
closes it except where the drain is inserted, and attaches great
importance to filling the abdomen with salt solution ; and en-
tirely avoids drainage with plain gauze. Since adopting this
technique he states that his mortality has fallen from 90 per cent,
to II per cent. He strongly objects to evisceration, partial or
complete. In the discussion which followed the reading of this
paper. Dr. Jacob Frank stated that the only two cases of diffused
septic peritonitis that he had ever had recover in the last twenty
years were treated on the lines advocated by Dr. Knott. Dr.
Eisendrath had met with similar remarkable success by using
the Fowler position, avoiding evisceration, but flushing copiously
with saline. He pointed out the possibility of similar success
by diflerent methods, Dr. Murphy by non-irrigation saving
fifteen out of sixteen, and Dr. Mordecai Price saved the whole of
seventeen cases by flushing. Others remarked on the importance
of not overlooking the right renal pouch ; and a heroic fact was
mentioned, in which a surgeon reopened the abdomen of his own
son eighteen hours after an operation by another surgeon, then
absent, and by means of the treatment advocated by Dr. Knott
saved the boy^s life.
He :K He * *
It is well known that after operations for generalised peritonitis
there is often a considerable amount of distension or even intesti-
nal obstruction. The surgeon is then in doubt as to whether
anything further should be done. Dr. H. Lilenthal records a
case in which, after operation following peritonitis with symptoms
of obstruction, he reopened the abdomen above the umbilicus,
let out a quantity of fluid, and performed a temporary enteros-
tomy on a much-distended loop of jejunum, which he subsequently
closed by a secondary suture, the patient recovering. 1 It may
^ Ann. Surg., 1905, i. 944.
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246 PROGRESS OF THE MEDICAL SCIENCES
be'marked^that the evidence is not clear that the enterostomy was
the sole reason of success ; it may be that the liberation of the
fluid was the more important factor in the relief of obstruction.
The subject was discussed at a meeting of the British Gyneco-
logical Society,! when Mayo Robson recapitulated the lines of
treatment already referred to. Differences of opinion were ex-
pressed, some recommending morphine and alcohol with free
abdominal flushing, some free purgation by salines or calomel,
and some the application of ice at the onset of peritonitis. It
cannot be said that the subsequent discussion revealed full
practical acquaintance with the advantages of modem treat-
ment. The same may be said of a discussion on the subject at
the Royal Academy of Medicine in Ireland. 2
Before the Royal Medico-Chirurgical Society, Mr. Malcolm
expressed views concerning inflammation similar to those
previously expressed by Bantock, his view that peritonitis was
due to irritation and the temperature simply a nervous reflex
being met by arguments from Mr. Dudgeon, who showed that in
even the so-called sterile exudate of peritonitis, micro-organisms
chiefly staphylococcus albus, could be found. ^ *
* * * * . *
There are two forms of acute peritonitis, pneumococcal and
puerperal, which demand attention ; the former in particular
having come into special prominence of late. Dr. F. S. Mathews
read a paper on *' pneumococcal peritonitis," with a report of five
cases. * He also refers to two papers on the same subject, one by
Jensen comprising 106 cases, » and one by von Briins.« From a
consideration of these papers it is seen that pneumococcal perito-
nitis is three times as frequent in children as in adults, and that
although the sexes are equally affected in adult life, in children
it is seven times as frequent in girls as in boys. The peritoneal
exudate is copious, thick, and odourless, with a tendency to
localisation. The majority of cases have been primary in the
peritoneum, and some have been associated with or followed by
pneumonia, empyema, pericarditis, otitis media or intestinal
lesions. The most characteristic symptoms are : (i) Sudden
onset with fever ; vomiting for a day or two ; slight pain, tender-
ness and distension ; little muscular rigidity. This is followed
by an improvement in the symptoms. ^ (2) Then, with the increase
of exudate, there appears a tense cystic mass in the hypogastrium,
the temperature rises and becomes of remittent type, succeeded
by cachexia, weakness, followed by death or recovery after opera-
tion. The localised form is more amenable to successful operation,
80 per cent, being successful. The differential diagnosis is difficult,
^ Brit. M. J,, 1907, i. 1483. -^ Ibid., 1906, i. 862.
3 Ibid., 1905, ii. 1 1 16. * Ann. Surg., 1904, ii. 698.
^ Jensen, Arch. /. klin. Chir., 1903, Ixx. 91.
^ Von Briins, Beit. z. klin. Chir., 1903, xxix. 57.
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OPHTHALMOLOGY. 247
and no definite distinguishing point can be stated. The modes of
pneumococcal infection of the peritonemn are as follows : through
a wound, through the diaphragm, through the genitals, through
the intestinal tract, through the blood, and from pneumococcic
foci in abdominal organs. It is interesting, however, to notice
that in cases of pneumonia, pneumococci may be present in the
peritoneum without causing peritonitis.
With regard to puerperal general peritonitis, one may refer to
a paper by Dr. EUice McDonald on the subject, i Of eleven
cases under his care, four were associated with streptococci, two
with staphylococci, one with pneumococci, one with gonococci,
and three with multiple infections of the streptococcus associated
with the bacillus coli, gonococcus, or the bacillus aerogenes
capsulatus. It will thus be seen that puerperal peritonitis is
usually streptococcic and usually fatal, though not invariably so.
The staphylococcus aureus has been rarely found, and although
the gonococcus is such a frequent cause of salpingitis, it is not so
commonly the cause of puerperal peritonitis. For further details
and references to this subject the paper may be consulted ; but
with regard to the surgical aspects of the question, there seems
to be evidence that polyvalent anti-streptococcic serum may be
of some utility, used in association with operation after the
method of Murphy for peritonitis in general. That the results
are improving is shown by a collection of 121 cases by Jeannin,
with nearly 50 per cent, of recoveries.
T. Carwardine.
OPHTHALMOLOGY.
At a recent meeting of the Ophthalmological Society held in
Edinburgh, 2 Sydney Stephenson read a most instructive paper on
the subject of the " spirochaeta pallida in relation to the syphilitic
affections of the eye. He prefers to call the organism of Schaudinn
by its newer name of treponema pallidum, which organism has
now been found in all forms and stages of syphilis, whether
acquired or inherited, human or animal. From the ophthalmic
point of view the following facts may be stated : (i) The tre-
ponema has been found in the apparently healthy eyes of foetuses
and of infants who have died from congenital syphilis ; (2) It
has been found in lesions set up experimentally in the eyes of
animals by the inoculation of syphilitic material, such as chancres
or diseased glands; (3) It has been found in actual syphilitic
invasions of the human eye. The conclusion is inevitable, that
in the discovery of Schaudinn's oganism we have the strongest
possible proof of the syphilitic nature of any given disease of the
eye. A point concerning interstitial keratitis may be cleared up^
by our present knowledge, which has long been a mystery. The
* Ann. Surg., 1907, i. 203. * Ophthalmoscope, June ist, 1907.
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248 PROGRESS OF THE MEDICAL SCIENCES.
existence of spirochsetes in the cornea, iris and choroid of the
syphihtic infant gives us a hint as to how interstitial keratitis-iritis
and choroiditis may be brought about later on in life. Although
most of the protozooa may succumb to the natural defensive
powers of the body, yet some may remain latent, perhaps in a
resting stage, like the trypanosome, until roused into renewed life
and activity by an exciting cause, possibly years after the original
invasion. On this theory it becomes comparatively easy to
understand why in predisposed subjects local injury is so com-
monly an exciting caus^ of interstitial keratitis, and why a history
of traumatism is far from unknown in choroiditis in those who
have acquired a hereditary syphilis. The persistence of a few
spirochaetes, whilst most had undergone destruction, would ex-
plain the relapses now and then observed in cases of interstitial
keratitis, and similar considerations would account for the re-
currences, not infrequent, of syphilitic choroiditis. In relation to
this, it may interest the members of the Society to remember a
case of interstitial keratitis with disseminated choroiditis recently
shown at the Society's clinical evening. I mentioned the frequent
occurrence of injury as an immediate cause of the specific inflam-
matory attack, and quoted three cases, two of brothers who had
normal eyes till over twenty, when one developed keratitis follow-
ing an injury from dust blowing in his eye, the other one
keratitis, from a blow with a hammer in the eye, In each of these
case the keratitis came on in the injured eye, but quickly spread
to the uninjured organ. The third case was a man who went on
apparently with good e^^es till the age of 35, when a blow from a
twig set up an irritation which ended in a definite attack of
interstitial keratitis.
With interstitial keratitis on one's mind, its exceedingly slow
course and the difficulty of finding a remedy naturally occurs to
one. Mercury and potassium iodide, although no doubt both
excellent in their way, seem to take less effect in interstitial
keratitis than in any of the other eye troubles due to sypliilis.
Iritis and choroiditis both yield to their influence as to a charm,
but keratitis distinctly hangs fire. Latterly dionine has come into
vogue, and in dionine a good friend has been found. Combined
in an ointment with atropin, in the proportion of dionine 2 per
cent., atropin i per cent., an excellent result may be obtained.
The application in the form of ointment introduced between the
lids seems to take much more effect than when used as drops.
Possibly the ointment, adhering to the conjunctiva for a longer
time than the drops remain there, may have something to do
with it ; but be that as it may, dionine and atropin ointment have
for me worked wonders when all other remedies have failed
miserably. I can recall a young lady, whose interstitial keratitis,
a very definite attack too, got well in exactly three weeks. I had
prepared her, as I always do, for a long course of treatment, and
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OPHTHALMOLOGY. 249
mentioned three months as a likely period. This is my own
experience. Listen then to the experience of others. Kari
Grossmann, of Liverpool, says^ of dionine, ''yet it is a drug which ^
I if once used, with discrimination and without prejudice, is not
j likely to be omitted from the oculist's outfit. Though a derivate
I of morphia, it is characterised by the comparative absence of its
! toxicity, which makes it a safe remedy in eye practice. When
brought into contact with the conjunctiva, either in solution,,
ointment, or in substance, a burning sensation is soon followed
bj' lachrjonatidn and fine injection, often combined with reduced
sensibility ; on the ocular conjunctiva a fine cobweb of lymphatic
vessels becomes visible, and is gradually swallowed up by a
more or less strongly-developed chemosis, which often covers
the corneal limbus by a sausage-like swelling. The lids swell
to such an extent that they cannot be opened, and this state
reaches its maximum in about half an hour, when the oedema
gradually lessens, to disappear in three to six or even twelve
hours.''
The action of dionine on the eye is a powerful lymphagogue";
it acts, however, as an analgesic as well, but not as an anaesthetic,,
like cocain. In iritis and iridocyclitis, Grossmann considers we
come to the affections in which dionine appears to do most good,
and here the analgesic effect on the deep-seated pain is most re-
markable. Every now and then one comes on a case where
dionine does not produce its usual chemotic action, and in these
cases it does least good ; furthermore, eyes soon become used to-
dionine, and after the fourth or fifth application the chemosis is
almost nil. xAs soon as this takes place its good effect also
disappears, and increasing the dose, even to dusting the eye with
the actual powder itself, produces but little reaction ; its use
should, therefore, be discontinued for several days, when once
more its beneficial results will be apparent.
* * * * *
Thompson Henderson has written an excellent article on the
healing of the corneal wound in cataract extraction. ^ This paper
is based on the examination of thirty-three eyes which had been
operated on for cataract. In all these the clinical process of
healing was progressing, or had progressed in a perfectly normal
manner. In twenty-one of the cases death supervened from
some intercurrent affection, in a period varying from three days
to a month after the date of operation ; in four the eyes were
enucleated for pain and secondary glaucoma, while eight specimens
were obtained from the post-mortem room. This gives a very
good range to judge the healing processes by. He points out that
in an experimental corneal incision there is a greater retraction of
the anterior and posterior than of the central corneal layers, so
^ Folia Therap., 1907, i. 53. ^ Ophth. Rev., May, 1907.
Digitized by VjOOQIC
250 PROGRESS OF THE BIEDICAL SCIENCES.
that the margins of the wound, instead of appearing as two straight
hnes, show curved surfaces, meeting and touching in the middle,
giving the appearance of two triangular spaces with bases
respectively in and out. In cataract extraction wounds this
appearance, while present, is modified and not evident, on account
of the nature and position of the incision. Irregularities of the
opposing surfaces are not uncommon, in consequence of the
sawing movements with which sections are often completed,
giving the wound track a notched, wavy or step-like appearance.
He divides the process of repair into three stages : mediate union,
primary union, permanent union and cicatrisation, the last
of which, he points out, takes a much longer time to accomplish
than is generally thought.
Mediate union is brought about by a fibrinous exudate, which
glues the margins of the wound together at that point where the
distance between them is least. This fibrinous plug is sufficient
to retain the aqueous and allow of the restoration of the anterior
chamber. He thinks the fibrinous plug is chiefly, if not altogether,
a derivative of the altered aqueous humour, as in non-perforating
wounds of the cornea, the cut surfaces show little or no fibrinous
deposit.
The primary union stage is effected by the surface epithelium
and the posterior endothelium. These layers proliferate and
grow down the respective margins of the incision till they meet
and cover not only the lips of the wound, but also the fibrinous
plug that brought about the mediate union. This stage takes
very varying times in its accomplishment, from three days to
even a fortnight, or even longer after the operation. This dis-
parity is ascribed to the personal factor of the vital activity of
the tissues in different cases. Th's epithelial growth introduces
one of the dangers following extraction, if the wound remains in
a gaping condition, or the fibrinous plug is not strong enough to
resist the growth of epithelium. This latter grows down and
over the edge of the corneal wound, and may eventually progress
over the posterior surface of the cornea on to the surface of the
iris, and so block the corneo-iritic angle, causing glaucoma, for
which two of the eyes were eventually enucleated — four and five
years respectively — after what at first had been looked on as
most successful operations.
While the stratified epithelium on the surface of the cornea is
descending into the outer part of the wound, the endothelium on
the posterior surface by a similar process lines the inner aspect
of the incision to the completion of this primary union. Henderson
points out that primary union in a corneal flap incision is thus
brought about and completed without the parenchyma pla5dng
any part in the process; and judging from the series of cases
examined, it is certainly not till the sixteenth day that the corneal
elements proper manifest any active sign of reparative activity.
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REVIEWS OF BOOKS. 25I
that is, not before the average patient in this country is discharged
from hospital.
Permanent union is brought about by a slow and gradual
growth of the corneal fibres ; these, by their pressure on the
epithelial plug, cause it id atrophy and finally to disappear
entirely. The interspace between the two cut siuiaces is thus
reduced to a vanishing point, so that the normal radius of curva-
ture of the cornea is restored.
Firm and permanent cicatrisation is not accomplished for
two, three or more months, but when completed it is the exclusive
product of the corneal parenchyma, with a course which it is
scarcely possible to follow in its entirety. This length of time
in regeneration explains a point with which we were often struck
in cases of discission for congenital cataract, viz. the ease with
which it is possible to reopen a paracentesis wound, even as long
as three weeks after it had been first made, with an ordinary
repositor, by making quite a gentle pressure on the upper edge
of the corneal wound.
A. Ogilvy.
IReviews of IBooWe.
Manual of Anatomy. By A. M. Buchanan, M.A., M.D. Vol. I.
Pp. xvi., 596. London : BaiUiere, Tindall and Cox. 1906.
The student who is anxious to avoid knowing too much — and
he is not uncommon — will welcome this book, because it seems
small, and not overburdened with facts. It is a complete surprise
to find that so much information has been conveyed in so small
a voliune. The matter has been well selected, the diction is
terse and simple, the mmierous illustrations are quite as good
as in any English text-book, and one cannot help thinking that
this book will prove a serious rival to the much more bulky
works, such as Gray, Morris, &c., and we shall indeed be sur-
prised if a successful career does not await this book, if the
second volimie be as good as the first, the student will welcome
a volume of so convenient a size which at the same time contains
such a fund of information.
It is, however, unlikely that in a first edition such a book
should be absolutely free from blemishes, and there are a few to
which we think well to draw the attention of the author.
The account of the development of the chondro-craniimi is
that which is found in all the text-books. It is not only anti-
quated, but absolutely erroneous. It has long been pointed out
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252 REVIEWS OF BOOKS.
that the notochord has a quite different relation to the chondro-
cranium from that represented here ; it is also well-known that
the terms '* parachordal *' and *' trabeculae " have no real warrant
in the human skull. The accounts of the processes of ossification
of the various bones will bear revision, such as those of the malar.
bone, the mandible, the upper jaw, the sphenoid, the seventh
cervical vertebra, the sacrum, the coracoid process of the scapula
and ribs, and maybe others.
Speaking generally, the general description of the bones is
good, and most of the illustrations are of high excellence, and a
credit to the artist. Fig. 84, though very good, is too small ; and
Fig. 65 does not quite correspond with the text, for although the
'* nasal groove ** on the posterior surface of the nasal bone is
shown correctly running down to the middle of the lower margin of
the nasal bone, and is said in the text opposite to contain the nasal
nerve, yet a nasal notch quite unconnected with this groove is said
to convey outwards the terminal cutaneous branch of the nasal
nerve. In the description of the cervical vertebrae, the costal and
transverse processes are carefully described and distinguished
from one another, yet in the description of the seventh cervical
vertebra both are alluded to as transverse processes, and the old
terms '* anterior and posterior tubercles *' are used.
With regard to the thoracic vertebrae, more might have been
made of the distinguishing characters of the eleventh vertebra,
especially worthy of mention being the fact that the inferior
articular processes, or if not they, small tubercles at the root of the
spine project below the plane of the body and spine, which never
happens in the tenth or those thoracic vertebrae above, but always
in the twelfth and all below. That very characteristic feature of
the fifth lumbar vertebra, viz. the springing of the costal process
from the body, might have been made more of, as well as the fact
that the transverse diameter of the neural arch greatly exceeds
its vertical.
With regard to the long bones, one notices the old fiction
repeated, *' that during foetal life the fibula articulates with
the femur ; '* and the same error with reference to the attach-
ment of the pronator teres to the radius is repeated.
One notices that the structure of the calcaneum is not quite
intelligible as rendered here, and the area of attachment of the
inner head of the accessorius is surely much too small.
The sections on muscles and arteries and nerves of the lirabs,
which complete the book, leave little to find fault with ; but one
feels bound to call attention to the scanty description of the
articular branches of the external popliteal nerve.
With the exception of the blemishes to which we have drawn
attention, and which no doubt will be remedied in editions which
we feel sure will follow. Volume I. is excellent, and we strongly
recommend it to the notice of the student who is not doing Qie
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REVIEWS OF BOOKS. 253
most advanced work. It is a creditable addition to the already
large number of students' text-books of anatomy— creditable alike
to author, artist and pubUsher.
Caneer of the Breast and its Operative Treatment By W. Samp-
son Handley. Pp. xii., 232. London : John Murray.
1906.
The aim of the author is " to present for the surgeon's use a
careful picture of a breast cancer, of its microscopic ramifications,
and of its mode of dissemination, and upon this basis to discuss
the methods of operative treatment." Questions of aetiology,
pathogenesis, and diagnosis are not considered.
The greater part of the work is devoted to the development of
an original h5^othesis, that of ** lymphatic permeation," to ex-
plain the mode of dissemination of cancer of the breast.
By this hypothesis, which is likely to be handed down to
posterity as *' Handley 's (Ljonphatic) Permeation Hypothesis,"
the master process in the dissemination of cancer of the breast
is the spread of the growth along the fine lymphatic vessels of
the parietes, independently of the transport of cancerous particles
by the lymph and blood streams. The existence of the latter
mode of dissemination, the " emboUc " mode, is admitted, but
it is not considered to be the chief process at work. The chief
process is a tendril-Uke growth of cancer from the primary
deposit in all directions in the fascial plane along the l5miphatics,
the growth being independent of the current of lymph. In the
parietes the extension is not primarily in the skin, but in the
" fascial lymphatic plexus," which lies in the subcutaneous fat
upon the deep fascia.
After giving a lucid and excellently illustrated account of the
macroscopic and microscopic investigations upon which the
permeation hypothesis has been founded, the author proceeds,
in the final chapters, to enunciate the principles which should
underlie the operative treatment of breast cancer, and he suggests
modifications of technique which are likely to improve the results
of these operations if his hypothesis of dissemination represents
the truth.
In our opinion it is the plain duty of every surgeon who
operates for mammary cancer to give due consideration to the
views which the author has advanced. We beUeve that in time
all surgeons will become acquainted with them more or less
thoroughly, for they seem to be endowed with " permeative "
force. We advise that the acquaintance be made a thorough one
at once, through the medium of the author's book itself. If we
mistake not, the investigations he has recorded will mark an
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important epoch in the history of the campaign against cancer
of the breast ; but whether that be so or not, the fact remains
that the book is one of conspicuous merit and fascinating interest.
The Essential Similarity of Innocent and Malignant Tumours. By
Charles W. Cathcart, M.A., M.B. Bristol : John
Wright and Co. 1907.
Some eighty-six admirably reproduced photographs are
appended to seventy-nine pages of letterpress. The|latter con-
cerns itself with the question of the relations existent between
innocent and malignant tumours. The writer sets out to prove
that there is a definite demonstrable gradation from innocent to
malignant tumours, that this transformation in character may
sometimes be observed in the same tumours, and that combina-
tions of character may sometimes be met with.
The examples of these conditions are chiefly drawn from bony
growths, and while we must admit that a good case is made out,
it is a moot point whether the conclusions drawn from bony
growths may be applied to other tumours. However, the matter
is one of general interest, and the surgeon will find a perusal of
this book both suggestive and helpful.
The impression gained from the arguments advanced is an
enforcement of the doctrine of ** original sin.** All tumours are
deemed to possess latent malignancy, even though they appear
to be temporarily innocent.
Antenatal Pathology and Hygiene : the Embryo. By J. W.
Ballantyne, M.D. Pp. xix., 697. Edinburgh : William
Green and Sons. 1904.
This volume is a most interesting and exhaustive statement of
the results of the author's researches in a domain of pathology
hitherto insufficiently subjected to scientific study. No pains
have been spared to obtain the fullest possible information on the
subject, and numerous specimens of various types of foetal
monstrosities and instances of congenital defects and abnor-
malities for the purpose of scientific description and classification.
It is difficult in dealing with such a work to decide on the parts of
it to which attention should be directed. While it is necessary that
the whole volume should be read connectedly, in order that the
valuable information contained in it may not be missed, we may
still direct attention to portions of it which are perhaps of rather
more general interest than others. A most detailed and clear
account of the embryology is, with its chronology, given to com-
mence with, but, as the author very justly remarks, as regards
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human embryology our knowledge practically commences ^vith
the early ova described by Hubert Peters and Leopold.
We know nothing practically of the changes which occur in
the fertilised human ovum before the fifth day after impregnation,
which is the approximate date of the Peter's ovum, that of Leopold
being a little older.
Capital plates of sections of these two ova are introduced, but
unfortunately the reference lettering is not always as distinct as
it might be. One of the most interesting sections is the account
of experimental terato-genesis, detailing the experiments of the
St. Hilaires, Charles F6t6 and C. Darester on the incubation of
hens' eggs, showing how in various ways, by mechanical inter-
ference with the developing ovum or by subjecting it to various
toxic or unnatural thermal or other influences, it is possible to
produce various types of monstrous chicks.
He suggests that monsters are produced invariably by the
arrest of development of a part of the foetus at a certain stage,
while the remaining parts progress normally, and shows that
manj monstrosities are represented at certain stages of normal
development.
The chapter on maternal impressions should also be read care-
fully by those interested. He gives a most interesting historical
account of these so-called phenomena, and one or two curious
instances of his own researches into the origin of histories supposed
to be established as scientific facts. When a scientific writer
attributes to a certain observer as a fact observed and recorded
by him a statement which was to the effect that he had seen the
record made by another observer, it is easy to understand how,
among the uninstructed public in any country, the extraordinary
stories, many of which he quotes, become current and obtain
universal acceptance. The accoimt of the pathology of hydatid
mole is extremely interesting, and explains many of the more
intricate features of the pathology of that disease.
As we have already stated, it is extremely difficult to select
sections of a work of this kind ; it must be read as a whole, and will
amply repay the labour of perusal by anyone interested in the
subject. It is an excellent presentation in a truly scientific form of
facts hitherto isolated and often exaggerated in description,
classifying all the abnormalities described in a coherent and
rational manner, and giving the author's deductions from facts
observed by himself, or accurately recorded by others, in a manner
at once lucid and fort ible.
Biographic Clinics. By George M. Gould, M.D. Vol. HL'
Pp. 516. London : Rebman Limited. 1905.
Dr. Gould starts on the assumption that scarcely any recogni-
tion IS given by physicians, or even by ocuUsts, to the fact that
errors of refraction give rise to numerous discomforts, which
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might be removed by the application of suitable spectacles ; and
if the gravamen were true that the medical profession does not
fairly consider the conditions of eye-strain, and their bearings on
the treatment of migraine and other numerous discomforts, his
book would be of service in drawing attention to the undoubted
and well-recognised fact that the correction of astigmatism and
of refraction errors is frequently essential for the relief of numerous
patients, and very useful in helping many others.
But he seems to assume that he is preaching a new gospel,
while on the contrary he . is overstating and exaggerating the
value of a well recognised and very widely applied form of treat-
ment. He says : " The Continent of Europe still lingers in pitiful
barbarism upon this subject. When my patients return from
these benighted countries, they tell tales that should be gathered
for the amusement of coming and humour-loving generations."
"*' Patients suffering from eye-strain are the prey of the travelling
spectacle vendor, who should often be jailed, the quack optician
and oculist, the jeweller, who knows nothing of optics or of
ophthalmology.'*
At any rate, there seem numerous efforts being made to apply
the remedy which Dr. Gould appears to consider the one panacea
for all human illness. But we can assure him that refraction
testing is well understood, and is applied with every scientific
care by English oculists and by their colleagues throughout the
Continent of Europe, and that the book before us is not likely to
be of the least service in assisting the investigation of eye-strain
from any scientific or clinical or unique standpoint. The book
is amusing, and may give hope even to sufferers from incurable
maladies, that they may yet be relieved by what is arrogantly
•called the ** new ophthalmology."
No intelligent ophthalmic surgeon will find any help in the
book, except to encourage him to plod on with refraction errors,
with the certainty that some good will accrue to his patient from
the use of spectacles. The nasal surgeon is informed that errors of
refraction cause sinus disease. He will naturally retort, and with
good reason : " No, it is the sinus disease that caused the eye
symptoms, which you will in vain try to relieve by spectacles."
Migraine is no doubt very often due to eye-strain — everyone
has known this for many years — and English physicians always
send such cases to the oculist before they attempt any treatment
by advice or drugs. It is unfair to the practitioner to say that
•eye-strain is not always sought for as a cause of migraine : it is
unfair for any writer of recent years {o claim any originality for
suggesting the use of glasses in these cases. A narrow specialist,
an exaggerator who has become an extremist, has indeed become
a hobby rider in the writing of this book (p. 38).
John Addington Symonds is supposed to have suffered from
an uncorrected eye-strain, to which alone all his pains and weak-
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nesses are attributed ; but there is no positive evidence adduced
of any error of refraction or of muscle balance.
Taine's ill-health is attributed by Dr. Gould to a strabismus
and ptosis that he suffered from. But there are plenty of squinters
and those with paralysed eye muscles who do not suffer on that
account from any other defect of health. Eye-strain is often a
cause of headache, and may cause other neuroses. But many
neuroses exist, and headache may be present, without ocular
defects. The first inquiry in migraine should be as to the eye
conditions ; but migraine may be present without abnormality of
eye, and the correction of eye defect may be quite inoperative
against migraine sjonptoms.
The later chapters in the book are interesting, and show
considerable knowledge and investigation. Dr. Gould quotes in
support of his views writers of articles chiefly in 1904 and 1903.
But as long ago as 1893, an article insisting on the necessity for
careful testing of the eyesight and the conditions of the muscle
balance in asthenopia and ocular headache, &c., appeared in the
Bristol Medico-Chimrgical Journal. Writers in this Journal have
supported the view that careful refraction work and the proper
adaptation of glasses is an essential form of medical diagnosis
and treatment ; but they do not claim spectacles as an infallible
cure for all forms qf ill-health.
High Frequency Currents. By H. Evelyn Crook, M.D., B.S.
Pp. X., 206. London: BaiUiere, Tindall and Cox. 1907.
There can be no doubt that in certain forms of disease treat-
ment by the high frequency electrical currents is of very great
value, and it is in the hope *' that it may in some way help to
bring before the notice of medical men the undoubted thera-
peutical value of high frequency currents in certain pathological
•conditions, *' that the author submits this book to the medical
profession.
The first part of the book is devoted to a description of the
production of the currents, and of the various forms of ap-
paratus before the public for the purpose. This description is
most thorough, and moreover is given in a most lucid style, the
result being that it is one of the most valuable and helpful accounts
that we have met with.
The second part is devoted to the consideration of the physio-
logical effects of the currents, in which a very good summary of
the work of the best observers — more especially on the continent
— is given.
The rest of the book is given up to the consideration of the
therapeutical uses of high frequency currents, and it is this part
that will probably be of most interest to the practitioner. It
mainly consists of reports of cases by various workers, which
18
Vol. XXV. No. 97. ^ .
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prove undoubtedly that in tuberculous disease, rheumatic disease
of all kinds, &c., the high frequency currents are of very great
value.
This form of electrical treatment has perhaps suffered from too
much being expected of it when it was first introd\iced, and also,
perhaps, as is pointed out in the preface, " because it has un-
fortunately in many instances fallen into the hands of irrespon-
sible and unqualified persons ; *' nevertheless, it is of the greatest
use in certain forms of disease, and such treatises as the one under
review, written in a dispassionate and judicial way, will do much
to place the treatment on its proper footing in therapeutics.
Clinical Studies in the Treatment of the Nutritional Disorders of
Infancy. By Ralph Vincent, M.D. Pp. 83. London:
Bailliere, Tindall & Cox. 1906.
This little book is a supplement to the author's Nutrition of
the Infant, published a couple of years ago, and is a series of clinical
reports on infants treated in the Infants' Hospital. The object
of the author is to show that slight variations in the percentages
of the food stuffs make all the difference in the success or failure
of infant feeding, especially in the marasmic; rachitic or other-
wise abnormal babies who are brought into hospitals. The cases
are rather elaborately reported, and the milk prescriptions given
in full. On general principles we are in entire agreement with
the author. Careful milk prescriptions either worked out on
percentages of the chief constituents or on some other convenient
method, are the only means we have of regulating the feeding of
infants who cannot be brought up on the breast, and of restoring
to health those who have been improperly dieted. The very
small variations in diet percentages to which Dr. Vincent
attributes so much importance do not appear to us of proved
value when judged from the records in this book.
In the first place, the cases are apparei\tly selected, not simply
serial, and there is no evidence that if all the infants admitted
to the Infants' Hospital were included any better results would
be shown than are obtained in other Children's Hospitals, where
so much stress is not laid upon minute alterations in diet. Then
again, infants, even when carefully fed and looked after, show
curious alterations in the rate of growth and general condition
apart from small variations in diet. Dr. Vincent's own records
show that the children gain and lose weight when the diet is not
altered just as they do when it is. Certain comments in the book
seem to us of rather doubtful advisability. For instance on p. 40^
** In these cases " (presumably in half-starved infants when put
on more nourishing diet) '* the liver and tissues become engorged ;
the liver especially comes into a condition of stasis, and the food
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then acts as an irritant/' The exact meaning of the expression
" tissues *' is not clear, nor is the evidence of stasis of the liver
given ; apparently the fact that purgation and reduction of food
effects an improvement is regarded as a proof of the correctness
of the pathological theory. Again, on p. 14, describing a child
who at the age of three months weighed 7 lb. 5 oz., the author
remarks that the '* nervous condition was due to the terrible
deprivation of fat in the previous diet.*' Doubtless the previous
diet had been very deficient in fat, but we are not aware of any
evidence to show that deprivation of this food stuff alone induces
any special changes in the central nervous system either organic
or functional.
With Dr. Vincent's methods in general no fault can be found,
and we trust that the Infants' Hospital will continue to do good
work in a field where workers are much needed ; but we cannot
say that we are altogether convinced by the present brochure
that all Dr. Vincent's views will stand the test of further ex-
perience.
Encyclopedia and Dictionary of Medicine and Surgery. Vols.
II., III., IV. Edinburgh : William Green and Sons. 1907. — ^
The succeeding volumes of this great work are following each other
without delay. The first volume was noticed in our issue of
December, 1906, and thr.e others are now before us, carrying the
subject matter to the word Intussusception, and completing more
than one-third of the whole work. The four volumes now issued
contain almost all of the articles of the first five volumes of the
Encyclopcedia Medica, together with a great mass of new material,
consisting for the most part of shorter contributions. The names
of the authors are a sufficient indication of the quality of their
writings, it would be invidious to select any for especial com-
mendation, and the editorial part of the work is beyond all praise.
The numerous cross-references have been prepared with great
care, and add much to the value of the work as facilitating im-
mediate reference to all the aspects of any given subject.
A Dictionary of Medical Diagnosis. By Harry Lawrence
McKiSACK, M.D. Pp. xi., 583. London : BaiUiere, Tindall &
Cox. 1907. — ^This work is described by its author as a treatise on
the signs and symptoms observed in diseased conditions, for the
use of medical practitioners and students. It is therefore an
exposition of the language of signs as presented in the bodies of
our patients. The author endeavours to avoid the discussion of
diseases as they are described in the text-books of medicine, and
restricts himself to a description of the various signs and symptoms
of disease. The dictionary form is convenient for easy reference,
but some of the articles are of considerable length, notably that on
blood examination, which gives all needful details with regard to
the study of stained films, and the determination of the opsonic
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power of the serum. The author may well expect to be the
teacher over a much wider field than the Royal Victoria Hospital
of Belfast.
On Treatment. By Harry Campbell, M.B., B.S. Pp. viii.,
421. London : Bailliere, Tindall & Cox. 1907. — This is not a
text-book, but a series of essays, giving the personal point of view
of the author on certain questions of therapeutics. The subjects
are very varied, ranging from the education and personality of the
physician and his proceedure in consultation through a great
variety of interesting topics up to the latest fads in diet and
therapeutics. From the previous works of the author we should
expect a good literary product founded on common sense. We
are not disappointed, lor the book is full of sound teaching, and is
so interesting, that it may well take precedence over the popular
novel of the day.
Gout. By Arthur P. Luff, M.D. London : Cassell
and Co. 1907. — ^The issue of a third edition of this well-
known book shows that gout cannot yet be considered as an
extinct disease. In fact, as a source of polemical discussion, it
appears likely to afford some interest for another century or two.
The enthusiasm for golf and outdoor exercise at one time bid fair
to diminish the transmission of this favourite family heirloom, but
with the appearance of the motor hopes such as these speedily
vanished. Vibration, deficient exercise, increasing appetite, and
perpetual faucial dryness all prognose the recurrence of swathed
limbs and restrained expressions. Hence it is well to have at hand
a summary of recent work. Dr. Luff has considerably enlarged
his original monograph, and readers will find a clearly-stated
resume of the present views upon this most difficult subject. It
must be admitted that there is still much to be done before the
inner metabolic changes in gout are delineated, but it is satis-
factory to note that a toxic theory is substituted for the dis-
carded renal theory. Treatment is considered in detail, and a
new feature consists of the differential diagnosis in chronic diseases
of the joints. There is a very useful table upon the choice of a spa.
Bath is recommended as exceedingly good for the absorption of
gouty deposits from the joints and tissues. Harrogate is useful
for the same purposes, and also for gouty dyspepsia, hepatic
symptoms, glycosuria of gouty origin, and gouty skin affections.
Selected Essays on Syphilis and Small-pox. Translations and
Reprints from Various Sources. Edited by Alfred E. Russell,
M.D. Lond. Pp. xii., 215. London : The New Sydenham
Society. 1906. — ^This volume presents several papers of great
interest illustrating the progress of current experimental research.
It will be found very convenient for reference to have Schaudinn
and Metchnikoff's experimental investigations on syphilis, and
the studies of Calkins and Councilman on variola, all work of
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extreme importance, gathered together into a well-printed and
handy volume.
The Book of Prescriptions (Beasley). Rewritten by E. W.
Lucas. Eighth Edition. Pp. ix., 366. London : J. & A.
Churchill. 1905. — ^The popularity of this book has called for an
eighth edition, and there is now an introduction of two pages in
length by Dr. Arthur Latham. Dr. Latham says that the book
has been written to assist the senior student in his work at the
hospital ; if so, the senior student must be careful to distinguish
pharmacopoeial from other preparations, for there is little or no
distinction made for him. Should the senior student look up
podophyllin for a prescription to assist him in prescribing that
drug in a mixture, he will be disappointed, for the four prescrip-
tions given are all pills, and there is no mention of the ammoniated
tincture, nor of a suitable menstruum should the pharmacopoeial
tincture be used. He will be wise if he refrains from calling
sodium tartrate sodii citras (p. 279). He should also refrain from
learning certain prescriptions of the blunderbuss type, at any rate
before he is qualified, for he will find that a prescription containing
over twenty drugs will not be thought highly of by his examiners,
even though he plead that it is the *' Anti-Cholera Mixture,
R.C.P." But he may find, when he is qualified, that it is a useful
and up-to-date little book, which will often help him to make a
suitable mixture, or remind him of a line of treatment which he
had forgotten.
A Handbook of Medical Jurisprudence and Toxicology. By
William A. Brend, M.A., M.B., B.Sc. Pp. xiii., 287. London :
Charles Griffin & Company, Limited. 1906. — ^Though this is a
small book on a large subject, it is remarkably complete, and is
specially interesting from the large number of recent legal cases
which it embodies. We have tested it in numerous places, and
find that it is on the whole singularly free from omissions, though,
from its compressed style, students would not always see the
importance of the facts stated. Still, in the space which the
author has allowed himself, he writes clearly and with vigour,
so that his pages are by no means unattractive, even apart from
the cases he cites or describes from his own experience. We
shall hope to see an expanded edition later on, which should be
an invaluable book. The various chapters are of unequal value.
In the treatment of opium-poisoning there is no clear statement
of the curious excretion into the stomach of opium or morphine
circulating in the blood, which can be removed by repeated
lavage with permanganate after an interval. Even morphine
injected hypodermically can be thus recovered. Similarly in
the treatment of poisoning by arsenic, the quantities of sodium
carbonate and perchloride of iron to be used for forming ferric
hydrate might have been given in detail. The tests for phos-
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phonis are restricted to Mitscherlich's method, and the dangers
of phosphuretted hydrogen are omitted altogether. We should
also like to have seen some reference to the much debated pre-
cautions ordered by the Home Office as to the glazing of pottery,
and finally confirmed under the arbitration of Lord James of
Hereford. In fact, the account of several of the important
poisons is far too sketchy and brief. A much better chapter,
and one of general interest, is the one on ** the obligations statu-
tory and moral of the medical man." The law on malpraxis,
professional secrecy, undue influence, and death certificates is
here explained better than in most treatises of the kind. Indeed,
we know of none which sets forth so many recent decisions of
importance to the practitioner. Hutchison's useful list of the
ingredients of the common patent medicines, such as Cockle's
pills and pink pills, is given in an appendix. The book is well
printed in clear small type on good thin paper.
Medieal Diagnosis. By J. J. Graham Brown, M.D., and
W. T. Ritchie, M.D. Fifth Edition. Pp. xvi., 508. Edinburgh:
Wm. Green and Sons. 1906. — ^The success that this book has
obtained is well deserved, and the appearance of the fifth edition
is sufficient evidence of its popularity. It is hardly necessary to
say more than that this edition has been brought thoroughly
up to date, and may be relied upon as a trustworthy and complete
handbook for ordinary clinical work. It is profusely illustrated,
and the illustrations are good. The additions made add greatly
to its value. To those who know the book no further commenda-
tion is necessary, but we may add that its convenient size is
not the least of its recommendations.
Elements 0! Practical Medicine. By Alfred H. Carter, M.D.
Ninth Edition. Pp. xvi., 614. London: H. K. Lewis. 1906.—
A ninth edition is its own commendation : the book has fully
shown its adaptation to the needs of the student of medicine.
It has been carefully revised, and has not grown much larger.
The very full therapeutic index appears to be needful in these
days, when the tendency is to accept the ready-made combinations
of the wholesale druggist rather than to devise whatever may be
appropriate to the case and the occasion.
The Etiology and Diagnosis of Epidemic Cerebro-Spinal Menin-
gitis. By Archibald William Taves, M.D. Pp. 42. Providence,
R.I. : Snow & Farnham. 1906. — ^This essay won the prize
awarded by the Trustees of the Fiske Fund at the annual meeting
of the Rhode Island Medical Society in 1906. Its motto, " Keep
Watch,*' is a very appropriate one, inasmuch as epidemics of this
disease and sporadic cases also crop up unexpectedly here and
there, and diagnosis is difficult until a bacteriological examination
of the fluid obtained by lumbar puncture has been made.
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The British Journal of Tuberculosis. Edited by T. N. Kely-
NACK, M.D. Vol. I., No. I. January, 1907. London : Bailliere,
Tindall and Cox. — Another journal has been established in
furtherance of the crusade against tuberculosis. This, its first
number, contains a series of papers by the best-known writers
and authorities. We are told that " the time seems ripe for a
great forward movement against tuberculosis . . . and that here, '
as in other spheres, the future belongs to the brave.'* We trust
that the editor will have such support as will enable him to carry
on the campaign with the same energy and success as are shown
by the January number, which should be read by all who take
any interest in the attempt to combat tubercular diseases.
The Sigmoidoscope. By P. Lockhart Mummery, B.C.
Cantab. Pp. 88. London : Bailliere, Tindall & Cox. 1906. —
This is an elementary treatise based upon the author's experience
of his modification of Prof. Strauss's electric sigmoidoscope :
the first half of which describes the methods of using the instru-
ment, and the second half deals with some of the appearances
met with. There appears to be a limited future for this method
of diagnosis of diseases of the lower bowel which cannot be
adequately discovered by other means, and the assistance of
simultaneous air-inflation has diminished the dangers of sigmoido-
scopy, and increased its possibilities. At the same time, surgeons
of experience are well aware of the dangers attending the passage
of long rigid instruments through the rectum by the inexperienced.
The author records a case of perforation of the bowel into the
peritoneum by the sigmoidoscope, although he says " the only
danger which it seems to me might attend the use of the symoido-
scope is that of tearing the mesentery of the sigmoid." It is
doubtless an instrument of precision, essential in some cases to
accurate diagnosis ; but we predict that the average man will
do wisely by leaving such examinations to those specially ex-
perienced, lest he be tempted to pass the sigmoidoscope as Le
might a bougie, with results disastrous to his patient and dis-
tressing to himself.
Philadelphia Hospital Reports. Vol. VL Philadelphia :
Bradley Printing Co. 1905. — ^The first paper is one of local
interest, dealing with the first clinical reports issued by the
Philadelphia Hospital. The other papers deal with various
clinical subjects in reference to cases in the Hospital ; and we
are only doing justice to these papers when we say that they
maintain a remarkably high standard, and will well repay
perusal. The neurological articles perhaps especially deserve
mention.
Manual of Surgery. By Alexis Thomson and Alexander
Miles. Second Edition. Vol. L Pp. xxi., 808. Edinburgh :
Young J. Pentland. i9o6.-^The appearance of the second
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edition of this book in a little over two years testifies to its
popularity. The first volume has been increased in size by forty
odd pages. Some of the sections have been re-written, some of
the old illustrations replaced by better ones, and some additional
ones added. Specially is this noticeable in the orthopaedic section
at the end of the book. Also new are the photo-micrographs
illustrating surgical bacteriology. These alterations and additions
have added to the value of the work, which we still consider the
best modern text-book on surgery for students.
Glimpses of American Surgery in 1906. By C. Hamilton
Whiteford. Pp. 63. London : Harrison and Sons. 1906. — ^This
is quite an interesting booklet. In simple style we are told the
impressions of the author at several of the American surgical
clinics, notably of the Mayo Brothers, of Rochester, Minn. ; of
Murphy and Ochsner, of Chicago. The individuality of the
various surgeons is nicely caught, and though we have heard a
good many of the little trite sayings from the same mouths
before, yet they will be new, interesting and often amusing to
the profession in England.
Spinal Curvatures. By Heather Bigg. Pp. viii., 240.
London : J. & A. Churchill. 1905. — ^This book has been written
to advocate the mechanical as opposed to the gymnastic treat-
ment of scoliosis. The author not only recommends a support
for very advanced cases in which little good can be expected
from exercises for the spine, and for which most surgeons would
recommend one, but for all cases, at every stage of deformity.
The general opinion of surgeons at the present time is that such
mechanical supports have no curative action, but prevent further
deformity, relieve pain, and should only be used for cases too
severe for other methods of treatment. Heather Bigg, on the
other hand, maintains that such mechanical support is curative,
and he does not employ exercises to strengthen the spinal muscles,
but applies an instrument to support the thorax on the pelvis,
which is constantly worn in the day-time. We do not believe
that any form of such an apparatus can mould the deformed
spine straighter, but we do think that if the spine is supported
in this way during its period of growth it may in time grow straight,
or straighter, just as a bent tibia may when further bending is
prevented by a suitable splint. We are therefore inclined to
attach more importance to a supporting apparatus in the treat-
ment of scoliosis than many surgeons, but we do not think that
it should replace all other methods in cases which are hot too
advanced to be likely to derive benefit from them, and in
which there is no marked change in the shape of the bodies of
the vertebrae. Mr. Heather Bigg strongly objects to the
gymnastic method as advocated by Mr. Bernard Roth and others,
and he devotes a chapter to the consideration of Mr. Roth's
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REVIEWS OF BOOKS. 265
treatment ; but we cannot say that he shows that the gymnabtic
treatment is valueless, though perhaps some surgeons have gone-
too far in denouncing the mechanical support. At any rate, it is
interesting to read this original and well-written little book by
Heather Bigg, and consider both sides of the question. The
author goes very fully into the history of the treatment of
scoliosis, and there are many good illustrations of cases and
instruments in the book.
Grundriss der Orthopadischen Chirurgic. By Dr. Max David.
Second Edition. Pp. v., 240. Berlin : S. Karger. 1906. — ^The first
edition was published in 1900. The present one is considerably
enlarged. It is essentially a practical work, most of the text
being devoted to descriptions of the various deformities, and to
carefully-described details of their treatment. The etiology and
pathology are somewhat curtailed. The illustrations, although
not of great artistic merit, serve well their purpose, and are very
numerous. The authors quoted are for the most part German
and Austrian, and comprise a very good selection. Compared
with English surgeons, there is much more value attached to
gradual reductions and forcible wrenchings of deformities, and
also a greater use of plaster of Paris. The descriptions of the
many complicated instruments with the aid of diagrams is clear
and convincing ; these, especially in the cure of fixed joints, are
much more used abroad than with us. The importance also of
massage is not exaggerated. It is a work which would well
repay translation, and be of considerable use to practitioners in
England.
The Sequelae of Gonorrhea in both sexes. By W. Louis
Chapman, M.D. Pp.117. Providence : Snow and Farnham. 1905.
—A prize was awarded to the author for this essay by the Trus-
tees of the Fiske Fund, Providence. As stated in the preface, it
is largely a work of compilation of the most recently acquired
knowledge on the subject plus investigation on' the part of the
author in some original directions. • It deals very fully with the
subject embraced. Commencing with the bacteriology, and show-
ing that a gonotoxin may produce the symptoms apart from the
actual organisms, a chapter is devoted to the mechanism of
gonorrhoea and the importance of latent gonorrhoea. In dealing
with the sequelae common to both sexes, of special interest
perhaps are the . stomatitis of new-born infants, the various skin
invasions, which maybe of the nature of eczema, herpes, urticaria,
&c., and the affections of the nervous s^^stem, neuritis, &c. In
the sequelae peculiar to the male, attention is paid to the part
played' by the prostate, and the possibility of gonorrhoeal affec-
tion of that organ being a precursor to the enlargement of old
age ; and in those peculiar to the female, peritonitis and the effect
of gonorrh(^a in producing sterility are the most noticable
sections. Treatment is entirely omitted.
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266 REVIEWS OF BOOKS.
Women's Health, and How to take care of it. By Florence
Stacpoole. Second Edition. Pp. viii., 165. Bristol: John
Wright & Co. 1906. — ^This treatise is the outcome of much
thoughtful experience in nursing the ailments peculiar to women,
and is written in a plain, clear style that befits the subject. It
may be warmly recommended to women who wish to know how
to preserve their health, or to take care of the health of girls
under their care. It will be specially useful to young women who
have to live in lonely and distant parts of the world. The medical
information is cleverly reproduced, but the distinction between
anaemia and chlorosis is not clearly put. A particular excellence
of the book is the appeal not to neglect the early symptoms —
duly set forth — which may announce cancer of the uterus. We
like the chapter on the climacteric period, and especially the
advice as to diet ; but a few persons stint themselves too much
to maintain an unnatural slimness. There is perhaps rather
much prescribing, especially of iron, which should never be taken
except under medical advice ; but probably nurses only will
understand how to make use of the prescriptions. The book
may be read with advantage by young medical practitioners.
Medical Electricity. By H. Lewis Jones, M.A., M.D. Fifth
Edition. Pp. xv.,519. London: H.K.Lewis. 1906. — Dr. Lewis
Jones has added to the usefulness of his handbook by bringing it
up to date. The author, himself a pioneer in the electrical world,
gives what is best in the new work, and records new methods of
usefulness for the old. The chapter on X-rays has been largely
extended, and the electrical methods of dealing with various
skin diseases also find a place. The experiments of Leduc in
electrolysis are quoted, and a very useful addition to that
subject is made in this present edition. Dr. Jones has been
paying personal attention to the subject of introducing drugs
into the body locally by electrolysis, and as much interest has
been stimulated recently by the remarkable results obtainable
in rodent ulcer by the introduction of the ions of zinc, it is
valuable to have a treatise of reference for details of the technique.
The handbook is so well supplied with illustrations, and the
descriptions of apparatus, &c., are so easily followed, that we
have no hesitation in recommending this book to any who wish
I0 obtain some knowledge of the rapidly- extending subject of
medical electricity.
Climatotherapy and Balneotherapy. Bv Sir Hermann Weber,
M.D., and F. Parkes Weber. M.D. Pp." 833. London: Smith,
Elder & Co. 1907. — ^This volume on the climates and mineral
water health resorts (spas) of Europe and North Africa, including
the general principles of climatotherapy and balneotherapy, and
hints as to the employment of various physical and dietetic
methods, is practically a third edition of Sir H. Weber's book
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REVIEWS OF BOOKS. 267
on the Mineral Waters and Health Resorts of Europe^ but much
enlarged in respect to medical cHmatology. Questions of climate
and baths become of increasing importance as the facilities for
rapid and easy travel annually increase, and books of this kind
are soon out of date. Accordingly, we may welcome this volume
as a very comprehensive summary of everything known on the
subject, and giving the views of those whose experience must
command universal regard. We cannot attempt a review of a
book like this. It should be on the table for constant reference.
The Rontgen Rays in the Diagnosis of Diseases of the Chest. By
Hugh Walsham, M.A., M.D., and G. Harrison Orton, M.A.,
M.D. Pp. 80. London : H. K. Lewis. 1906. — Dr. Walsham is well
known as one of the pioneers in this country in applying the
X-rays to the diagnosis of chest disease, and, in conjunction with
Dr. Orton, he has given us this small volume, in which his
experience is summarised. The use of the rays for diagnosing
intra-thoracic disease is becoming nmch more general than
it was, but the profession at large is still unaware to a great
extent of its great value in diagnosis ; and the authors have
done well in drawing attention to this by saying that although
it is now ten years since attention was drawn to the subject.
" yet to-day the mass of practitioners in this country are quite
ignorant of the value of the rays in the diagnosis of chest diseases.'*
This little book ought to have a wide circulation, and will go far
to remove this want of knowledge, which is much to be deplored.
The value of the rays in diagnosing early phthisis is now generally
admitted, and the chapter on this subject is one of the best in
the book. The importance of the symptom of impaired move-
ment of the diaphragm as seen on the fluorescent screen, which
in many cases is present before any physical signs can be made
out is rightly insisted on ; and by skiagraphy it can often be
demonstrated that disease has attacked both lungs, where only
one shows signs of disease by physical signs. A number of cases
illustrating these and other conditions are given. In the chapter
on thoracic aneurism the difficulty and often the impossibility of
diagnosis is pointed out ; by means of skiagraphy, however, a
correct diagnosis can practically always be made, the authors
pointing out that to ensure a correct diagnosis the fluorescent
screen must be used and the thorax skiagraphed in more than
one position. This chapter, too, contains the records of in-
teresting cases of aneurism thus diagnosed. This charmingl}'
TOtten little book is one of the most important contributions
to the literature of skiagraphy that has appeared of late, and
is cordially to be recommended to the notice both of X-ray
workers — for the useful hints as to technique which it contains
— and also to all members of the profession, as it points out to
them the great assistance that they will receive from skiagraphy
in all chest diseases, especiaUy in those which are more or less
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268 REVIEWS OF BOOKS.
obscure. It should be mentioned that the excellent reproductions
of skiagrams, which elucidate the text, are quite one of the features
of the book.
Lessons on Massage. By Margaret D. Palmer. Third
Edition. Pp. xvi., 272. London: Bailliere, Tindall and Cox.
1907. — ^This book has had a large circulation, and several new
chapters have been added in this edition. It is an instruction on
the methods of massage ; the elementary anatomy and physiology
necessary for this is also included. As such it is clearly and
concisely written, and easily understood by nurses, for whom it is
especially meant. It does not pretend to advise as to which cases
should have massage, or to discuss the reasons why the movements
bring about the required results. Many conditions which are
greatly benefited by this treatment are not even mentioned, and
as it is no part of the trained masseuse to know them, it is probably
wise that they have been omitted. One point insisted on is very
important, namely the great advantage of working without
lubricant or powder where possible. It would add to the utility
of the work if some diagrams were introduced showing the direc-
tion and extent, by means of arrowed lines, of the various excur-
sions made by the hands. Swedish movements are not dealt
with, though these, and especially the respiratory exercises, ought
to be known to every masseuse. The book just covers what is
required in the examination of the Incorporated Society of Trained
Masseuses.
Lectures on Massage and Electricity in the Treatment ot
Disease. By Thomas Stretch Dowse, M.D. Sixth Edition.
Pp. xii.. 447. Bristol : J. Wright & Co. 1906. — We have been
frequently called upon to review this book, and the sixth edition
has not grown larger than the fourth. The author directs atten-
tion to the great and increasing appreciation of the value of
massage as a remedial agent. His book has done much to bring
about this result, but he regrets that the long-continued resistance
to massage in this country has led to much abuse of this method
in unqualified hands — " a good masseur should possess skill,
intellect and judgment ; but, above all, he must be a good
manipulator.'' A close study of this book cannot fail to be of
great value, both to those who prescribe and who perform massage
and use electrical methods of treatment.
The Uses of X-rays in General Practice. By R. Higham Cooper.
Pp. X., 98. London : Bailliere, Tindall and Cox. 1906. —
X-rays in General Practice. By A. E. Walter, Captain l.M.S.
Pp. xii., 175. London : John Lane. 1906. — ^To quote the preface
of the first of these books, " the intention of this little book is that
of giving the general practitioner some idea of the help he may
get in his practice from the use of the X-rays,'* and admirably it
fulfils its object. It is quite a pleasure to come across a book so
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REVIEWS OF BOOKS. 269
absolutely devoid of " padding/* and to have a plain and straight-
forward account of the author's own method of work, and his
experience of the use of the X-rays, both in diagnosis and treat-
ment. After a masterly short summary of the physics of the
X-ray, the author goes on to give in a most lucid way directions
for working an induction coil with an improved pattern of the
ordinary platinum break, wisely referring the reader to larger works
on the subject for details of the more elaborate breaks which may
be beyond the reach of the ordinary practitioner ; and then pro-
ceeds to discuss the use of the rays in diagnosis and treatment. In
the former most practical directions are given for taking skia-
grams, such as the position of the tube as regards the part that
is to be skiagraphed, length of exposure required, &c., &c., and in
the latter the author confines himself entirely to a record of his
own work, and gives the results of his own personal experience in
the treatment of the various diseases in which the X-ray is used
■as a method of treatment. We can cordially recommend this
little manual to all X-ray workers, not only to the novice, but
also to the more advanced worker, who will find in its short 88
pages more that will be of practical use to them than in many
volumes of much more pretentious size.
The second of these books is addressed to " the general prac-
titioner, the student, and other non-experts in the X-rays. '*
Like many other books on the subject now before the medical
public, it gives advice as to choice of apparatus, how to set about
taking a skiagram, &c. ; but perhaps the most interesting part
of the book is the account the author gives of the equipment he
has devised for active service in the field. There are a number
of most excellent illustrations ; the one facing the title-page of
a Chinese woman's foot, and of the skiagram of the same later on,
are of special interest because of the difficulty in obtaining them,
owing to its being *' considered an act of the utmost indehcacy "
for a Chinese woman to expose her foot. To the lover of personal
detail, it may be of interest to have reproduced for his benefit the
actual lesion which occurred when Lord Kitchener broke his leg —
an ordinary fracture of the tibia and fibula. (We wonder
whether Lord K. would be equally pleased ?) But we do take
exception to the statement on page 99 : " His Excellency Lord
Kitchener suffered a good deal when he first began to get about,"
and " he had a three weeks' course of high-frequency treatment,
and I have his authority for saying that he was much benefitted
thereby." This savours much more of the '* Electropathic
Institute" advertisement than of one of the volumes of the
Practitioner's Handbooks Series.
Transactions of the Epidemiological Society of London. New
Series. Vol. XXIV. Session 1904 — 1905. London : Williams
and Norgate. 1905. — ^Amongst the interesting series of papers
in this volume, probably the keenest interest will be felt in Prof.
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270 REVIEWS OF BOOKS.
MacWeeney's contribution, ** On the Relation of the Parasitic
Protozoa to each other and to Human Disease," and in Dr.
Nuttall's *' Ticks and Tick-transmitted Disease," which deal with
a subject that is now undergoing very rapid growth as knowledge
accumulates. Other subjects dealt with in this volume are
" Ankylostomiasis," ** The Etiology of Rheumatic Fever,"
" Phthisis Rates," ** The Spread of Small-pox occasioned by
Small-pox Hospitals," and the President (Dr. Whitelegge, C.B.)
contributes a paper on " The Epidemiological Aspects of In-
dustrial Disease."
Reports of the Society for the Study of Disease in Children.
Vol. VI. Session 1905 — 1906. London : J. and A. Churchill. —
The sixth volume of the reports of this young and vigorous
Society fully maintains the high standard of excellence established
by the preceding volumes. Dr. Whipham reports a case of
splenic anaemia, which illustrates the difficulties of the anaemias
of children when the splenic group is involved. Mr. Mackintosh
contributes a common-sense paper on diet during the second year
of life. We are surprised that a Society devoted to the study of
disease in children does not pay more attention to the important
question of feeding. The December meeting is occupied with a
full-dress debate on *' Pleural effusions, serous and purulent,"
which, owing to the eminence of the various speakers engaged,
may be regarded as a succinct summary of our present knowledge
of the subject. The Wightman Lecture was delivered by M. Broca,
M.D., of Paris, who took for his subject " Appendicitis : acute
and chronic." Dr. Bertram Rogers describes a case of acute
atrophy of the liver. In a valuable paper on '* Enlarged Veins
in Children," Dr. A. G. Gibson points out the importance of
enlarged veins on the thorax, in the diagnosis of enlarged tuber-
cular mediastinal glands in children, when associated with other
symptoms.
Index-Catalogue of the Library of the Surgeon-General's
Office, United States Army. Second Series. Vol. XI. — Mo—
Nystrom. Pp. 858. Washington : Government Printing Office^
1906. — ^This volume includes 8,023 author-titles, 5,634 subject-
titles of separate books and pamphlets, and 34,211 titles of articles
in periodicals. It may help the uninitiated to form some idea
of the immense amount of labour bestowed on the preparation
of this invaluable work if we mention that under the headings of
" Nerve," " Nerves," and '* Nervous " there arcabout 155 pages
of closely-printed references.
Wellcome's Photographic Exposure Record and Diary» 1907*
London : Burroughs, Wellcome & Co. Pp. 268. — ^This popular
pocket book has undergone its annual revision, and its infor-
mation brought up to date. The simplicity and convenience of
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REVIEWS OF BOOKS. 271
the mechanical calculator and light tables render the estimation
of the correct exposure for any subject an easy matter. It is an
■ excellent handbook for photographers generally.
The Influence of Cod Liver Oil on Tuberculosis. By J. W»
Wells, M.D., D.P.H. Pp. 83. Manchester: The University
Press. 1907. — Cod Liver Oil has for many years been looked
upon as a most useful agent in the treatment of consumption. Of
late it has been falling into disrepute, as it commonl}' forms no
part of the programme of sanatorium treatment. The experi-
ments recorded in this booklet, conducted in the Public Health
Laboratory of the University of Manchester under the supervision
of Professor Sheridan Del6pine, tend to show that '' pigs affected
with tuberculosis continued to increase rapidly in weight, and
appeared quite comfortable and happy for a long period when
the Cod-liver Oil Emulsion was added to the usual diet. Their
tubercle lesions showed signs of possible recovery, tuberculous
glands became fibrous and calcified, and the tubercle bacilli more
difficult to demonstrate." With this evidence before us, we may
well ask whether the use of Cod Liver Oil in the treatment of
phthisis should be discontinued.
Guy's Hospital Reports. Vol. LX. London : J. and A.
Churchill. 1906. — ^The present volume opens with a valuable
paper, by Dr. Frederick Taylor, on " The Chronic Relapsing
Pyrexia of Hodgkin's Disease," in which he records nine cases
where this disease was accompanied by relapsing pyrexia. He
points out that the temperature may be continuously high for long
periods, and that periods of higher fever may then alternate with
periods of lower fever, and that the recognition of the relapsing
form of pyrexia may be of assistance in the diagnosis of some
doubtful cases. Dr. Herbert French and Mr. H. T. Hicks write
on " Mitral Stenosis and Pregnancy," presenting in tabular form
statistics of 300 consecutive cases of mitral stenosis in women
over twenty who have been in Guy's Hospital. They consider
that the dangers of pregnancy in these cases have been overstated,
and that it is not just to negative marriage in all women with
mitral stenosis. Two highly interesting lectures, delivered at the
Physiological Laboratory, Guy's Hospital, by Dr. J. S. Haldane —
a brother of the present War Minister — on " Life and Mechanism,"
are here published. Dr. Haldane considers that while the old
vitalistic working hypothesis in physiology was altogether un-
satisfactory, the mechanistic hypothesis which some fifty years
ago replaced it, is inconsistent with observed phenomena, and
must also be rejected. In biology we cannot get beyond the
fundamental working conception of the living organism, which
is an organism, and not a machine. The lectures are expressed
in admirable language, and are worthy of thoughtful study. We
have no space to notice the other articles in this volume, which
are of unusual importance and interest.
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leDitonal IRotes.
The accompanying advertisement
Bristol Royal Infirmary : in the daily papers recites new rules
New Rules proposed. to be proposed at the next meeting
of the Board of Governors : —
)RISTOL ROYAL INFIRMARY.
B'
THE GOVERNORS are requested to attend
the HALF-YEARLY MEETING of the BOARD,
to be held in the BOARD-ROOM on TUESDAY,
24th September, 1907, at" 12 Noon.
The following alteration to the Rules will be
proposed : —
" THAT all appointments to the Honorary Staff
"to be made subsequent to the passing of this
•* Rule shall be held subject to the following regu-
"lations, in lieu of those contained in Rule 35.
•• RULE 36. — No member of the Honorary Staff
" shall hold any Union or Club appointment. No
" member of the full Staff shall hold any other profes-
"slonal public appointment other than Professorship
"or Lectureship at any University, College, or
" School. No member of the Assistant Staff shall
"hold any other General Hospital appointment, nor
" more than one special Hospital appointment.
"That the full Physicians shall limit their
" practice to medical work. That the full Surgeons
" shall limit their practice to surgical work. That
" each of the Specialists shall limit his practice
"to his speciality."
n^ * * n^
1 6th September, 1907.
Not far short of two hundred years ago — in 1735 — the Bristol
Royal Infirmary was founded by the happy association of lay and
medical philanthropists, and the partnership thus constituted in
*' Charity Universal/' the motto inscribed over the main entrance
to our oldest hospital, remains to this day the dominant spirit
controlling numberless hospitals that have followed in the wake
of this almost the first of provincial English hospitals.
Such a partnership must not be confused with a commercial
union, for, unlike business connections, the end and aim of both
medical and lay partners has not been simply self advancement,
but relief to the suffering and the advancement of medicine.
At a time when anything in the nature of prestige attaching
to a hospital had yet to be created, the profession of medicine
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r
i
EDITORIAL NOTES. 273
^ave its best, and then, as now, no new discovery or advancement
could be kept a trade secret for the aggrandisement of the
•discoverer, all being thrown into the common store of knowledge,
•so that rich and poor alike should derive the utmost benefit
possible. Hence the prestige of hospitals grew apace, and lay
philanthropists nobly responded to the ever-increasing call for
new and better hospitals, that cover the land in every civilised
•community. Have medical men ever lagged in fulfilling their
share in the partnership ?
Hospital doctors, and the general practitioners alike, have
lessened, to their own disadvantage, the toll that disease levies,
and the general public little know the constant charity of even
the poorest of general practitioners, any more than they will
ever know the measure of professional charity outside any
hospital walls of such men as Swayne, Long Fox, and Markham
Skerritt, whom we have so recently lost. These names, and such
men as Budd, S3mionds, Augustin Prichard and Greig Smith,
and countless predecessors in medicine and surgery, have raised
the prestige of our Bristol hospitals, as other physicians and
surgeons have done elsewhere, and in so doing, apart from their
gift in the work done, have also directly aided in securing
financial support for the buildings and endowments : they gave
a full measure and running over.
The governors to-day have inherited those buildings and
■endowments, and the doctors have inherited the prestige. Each
is a precious heritage — the one from the la3mien, and the other
from the doctors — to their respective successors and sons, and
we think we may fairly say that the representatives of each are
successfully maintaining and adding to their legacies, held in
trust for the Bristol poor. We have already, in our former note,
pointed out that this prestige is much overrated. Hospital
appointments are of little value in themselves, except in so far
^ they are opportunities for doing good work; and anyone
holding such appointments, and only doing as little as any
number of rules may demand, but failing to maintain the prestige
by enthusiastic devotion to the work he takes in hand, finds the
prestige is a tinkling cymbal. Are these easily-satisfied energies
Vol. XXV. No. 97. r^^^^T^
Digitized by VjOOQ IC
274 EDITORIAL NOTES
what our hospitals want ? Are these the kind of men that have
placed our British hospitals in the position they now occupy,
or who can hope in future to command the respect of their
medical brethren ? No, it is the man who takes infinite pains
over details, who is untiring in his search for knowledge, and who
is ready to go far afield in its pursuit, filling up spare hours where
opportunities arise.
In our last issue we referred to the question of dual appoint*
ments, because the committee of the Bristol General Hospital
had made ** vexatious *' use of their rule requiring the sanction
of the committee before any member of their honorary staff
accepted an appointment at any other hospital. The comedy of
a number of merchants, tradesmen, parsons and ministers,
stockbrokers and lawyers, having the right to decide how a
physician or surgeon may employ his spare time does not strike
these good and worthy gentlemen ; but as the case in question
was settled by the surgeon refusing to be bound by the veto so
arbitrarily exercised, we can cordially congratulate that
committee on rescinding their ruling ; yet how far better would
it be if they rescinded the derogatory rule.
Unfortunately it is this rule and ruling that has aroused the
committee of the Royal Infirmary, for during its two centuries
of existence such arbitrary powers over the medical staff have
never been constituted, and the staff would not willingly
subscribe to such an *' Act of Supremacy." But how much more
arbitrary, though perhaps less derogatory, are the new rules sought
to be imposed at the Royal Infirmary, since in future any physician
or surgeon or specialist who seeks election is forbidden to accept
any other public medical appointment — except a lectureship —
whether it be a paid office or an exercise of charity ! Inasmuch
as custom has determined that the staff at representative
teaching hospitals practise as pure physicians and surgeons
respectively, and provided the age limit at the Bristol
Royal Infirmary is raised to the usual 6oth year, we
see nothing to complain of in this custom being made
a rule, not only because it is due to the medical profession
and to general practitioners in particular that those of their
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EDITORIAL NOTE3. 275.
number who accept such opportunities should use them to the
highest interests and for the advance of medicine, but because,
the governors of a hospital have as much right to demand that
their physicians or surgeons shall be pure physicians or surgeons,
as they have to insist on their having certain degrees or diplomas ;
and they fail to do their duty if they do not get the best possible
skill for their patients. But by what right do the committee or
governors of the Royal Infirmary presume to dictate to their
honorary physicians or surgeons how they shall occupy their life
apart from their duties to the Bristol Royal Infirmary ?
The living governors and their lay committee have neither
built nor endowed the institution, and are mainly the inheritors of
the generosity of bygone ages, to which they add their quota.
So with the medical staff. Here, as elsewhere, they have not
made the prestige of the Royal Infirmary ; they inherit it from
their medical forefathers, but they, too, add their quota to the
good repute. The governors inherit the buildings and endow-
ment, and it is theirs to maintain ; but so, too, ^ the medical
profession inherit the medical prestige, and that is theirs to
maintain. But, alas! and here is the pity, the lay governor,
realising that there is a prestige attaching to his hospital, con-
siders it is his to manipulate even to the detriment of the medical
staff. If you serve our institution, they say, you must have your
charitable wings clipped and go lame. You medical men have
duties to perform in our hospital, and it is not enough that these
are faithfully and honourably discharged. It is not enough that
your forefathers have so raised the prestige of our hospital that
we can, and do, insist on your having the highest qualifications,
and practising as pure physicians, surgeons and specialists —
that you have suggested yourselves because it appeared a real
advantage to the institution — but notwithstanding this we
compel you, whether you like it or not, to accept terms which
are vexatious, if not derogatory, by binding you to forego any
other charitable effort, or to accept even any remunerated office
usually held by consultants. In your young years you may
waste your spare time in any way you wish, but one thing you
shall not do. You shall not, in your keen love of your
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276^ EDITORIAL NOTES.
profession, serve another hospital, to gain experience outside
our walls, that you may become better physicians or surgeons.
What should we say of the new landlord whose estate,
inherited from his forefathers, had been tilled and improved
and continuously raised in value by the labours of the tenant
through many generations of father and son, if he turned round
on his tenant saying. The loyal and devoted labour of your
forefathers has increased the value and status of the tenancy ;
what they gave so willingly, and in good faith, I will use to make
hard conditions for you ; if you don't like them, well, you have
your remedy — ^you can turn out ? Is this Charity Universal ?
We do not suppose for a moment that the generous and
honourable laymen of our hospitals are capable of deliberately
injuring or slighting their staff. It must surely be misconception
only that induces them thus to forget what they owe to the
medical profession, for medical science' is undivided, and is not
only national, it is international. If the medical work at British
hospitals is to be honorary, let it be continued as the charity
of the whole medical profession ; otherwise it should be treated
on true business lines, and duly paid for like the buildings, food
and nursing. Let us wake up, and see that the laymen do not
exploit the profession, and ruin our work with their so-called
** business principles." The blow is none the less hurtful because
it is dealt by friends.
About forty years before the departure of
John Free. Cabot on his voyage across the western
ocean, another less-noted but sufficiently
important enterprise had been embarked
upon by a pioneer of medical learning in Bristol. Attracted,
doubtless, by the reports of a revival of learning in the Universi-
ties of Northern Italy, John Free, with a few fellow-students,
accepted the offer of an Italian shipmaster to sail from the port
of Bristol to ascertain at first hand what new secrets of science
the Italian professors had to impart. Already Mondini and his
successor, Bertrucci (Guy de Chauliac*s master), had instituted
Digitized by VjOOQIC
EDITORIAL NOTES. 277
on a firm foundation the study of anatomy at Bologna, and more
than a century had passed since Mondini's first public demonstra-
tion of a human dissection. In France a papal bull had been
issued, permitting dissection of the human body in the Uni-
versity of Montpellier, but to England, engaged on the great
wars with France of Henry V. and VI., these advances in
science had not yet been introduced, though no doubt the inter-
course of French and English surgeons in the English army
had aroused some curiosity among English savants to go and see
for themselves what this strange way of studying the human
frame might be ; for Galen and his satellite commentators
reigned supreme in medicine still after the lapse of thirteen
centuries.
In 1449 Gilbert Kymer, who had been Rector of the Faculty of
Physicians in London when the abortive Conjoint College of
Physicians and Surgeons was set up (1423), admitted, in his
capacity as Chancellor of the University of Oxford, a certain
John Free, of Balliol College, to the degree of B.A., who in 1454
proceeded as M.A., and ultimately became a Fellow of his College.
As usual in those days. Free subsequently took Orders in the
Church, and although it is not known that he had any previous
connection with this city (for he had been bom in London), he
shortly came to Bristol and became Rector of St. Michael's in
monte (on the hill where it stands to this day). Of his hfe in
Bristol there is no record, but he had by then acquired something
of the reputation for culture and learning of which Leland speaks
with such admiration. Eventually, with three or four friends
stimulated by the same greed of knowledge, he found in Bristol
an Italian ship on which they took passage to the country where
the liberal arts had so recently revived. Pits states (overlooking
perhaps his connection with St. Michael's) that '* at length upon
quitting Oxford he resorted to Venta Belgarum, that is Bristol,
not for the purpose of remaining there, but in order thence to take
shipping for foreign parts, for his great desire was to visit Italy,
which he accordingly did.'
Free (or Phreas as he was called in Italy, according to the
custom of latinising the names of foreigners) studied at the
Digitized by VjOOQIC
278 NOTES ON PREPARATIONS FOR THE SICK.
'Universities of Ferrara, Florence and Padua, and settled as a
teacher of medicine in the first-named. His writings against
Diodorus Siculus gained for him the gratitude of the Pope
(Pius II.), who, wishing to reward his orthodoxy by some special
mark of favour, appointed him Bishop of Bath, which See had
just then fallen vacant. To this office he was never actually
consecrated, for he fell ill and died in 1465 before he could return
to England, poisoned, it was hinted, by those whose interest it
was that the bishopric should be otherwise bestowed.
The importance to medicine of this venture Irom Bristol can
scarcely be overestimated ; a rapid succession of students
followed in Free's footsteps. England was participating in that
intellectual intercourse with the centres of European learning
which culminated in the invitation of Erasmus to be Professor of
Greek in Cambridge, and the appointment of John Caius as Profes-
sor of Greek in Padua, whence he returned to organise the
scientific study of medicine in England.
Never before or since did England occupy' so high a position in
the republic of learning, and Bristol may recall with justifiable
pride that it was from our port that John Free set out *' qui
primus Anglorum erat, qui propulsd harharie, pairiam honesto
lahore bonis Uteris restifuit,** and that he set the example followed
by such masters of science as Linacre and Caius, Harvey, Locke
and Sydenham.
IRotes on preparations for tbe Sicft*
" Elixoid '* Formates Compound. — Burroughs, Wellcome &
Co.. London. — Each fluid ounce contains : —
Calcium Formate, gr. 12 (0.778 grm.).
vSodium Formate, gr. 6 (0.389 grm.). •
Magnesium Formate, gr. 6 (0.389 grm.).
It is claimed that the formates possess marked antiseptic and
diuretic properties. '* Elixoid ** Formates Compound presents a
convenient and palatable means of administering the formates of
calcium, sodium and magnesium without causing gastric disturb-
ance. Two fluid drachms may be taken thrice daily, in water,
after food.
Digitized by VjOOQIC
NOTES ON PREPARATIONS FOR THE SICK. 279
Quinine Acetyl-Salicylate.— Burroughs. Wellcome & Co.,
London. — ^This is another recent preparation brought out by
Messrs. Burroughs and Wellcome, and it is likely to be appreciated
by the medical profession.
Acetyl-salicylic acid, or " aspirin," has given satisfactory
results in cases where the use of salicylates was deemed necessary,
and the combination of this acid with quinine should certainly
give results justifying its introduction. No doubt it would be
hydrolysed in the duodenum with liberation of quinine and salts
of acetic and salicylic acids, and it is thought by some pharma-
cologists that better results are obtained when active products
are thus liberated by hydrolysis within the system, than when
they are directly administered.
Tabloids. — Burroughs, Wellcome & Co., London. — Ginga-
mint : soda-mint compound. — Each contains sodium bicarbonate,
gr. V. ; ammonium bicarbonate, gr. .* ; with gingamint, sac-
charine and oil of peppermint. This preparation is a valuable
antacid and stomachic, employed in the relief of dyspepsia,
nausea, heartburn and flatulence. It promotes appetite and
digestion, relieves griping, and produces a diffusible stimulant
effect.
Slippery Elm. — Mucilage of slippery elm is largely used as a
demulcent and sedative astringent. Alone, or combined with
phenol, it is employed locally in pharyngitis and other throat
affections, and internally in diarrhoea and dysentery. The
mucilage is also stated to have a nutritive value. " Tabloid "
Slippery Elm presents a convenient and reliable means of ad-
ministration. Each represents gr. v. (0.324 gm.) of mucilage of
slippery elm, and one may be slowly dissolved in the mouth or
swallowed whole with water as required.
" Tabloid " Carbolic Acid and Slippery Elm.— Each contains
carbolic acid, gr. ^ (0.032 gm.). One may be slowly dissolved in
the mouth, or one to two swallowed whole with water twice or
thrice daily after food.
Ernutin. — Burroughs, Wellcome & Co., London. — ^This drug
contains the specific active principles of ergot, the chief of which
is the alkaloid ergotoxine. It is physiologically standardised,
and presents a uniform degree of activity. For oral administra-
tion the dose is 30 to 60 minims. The tabloid for hypodermic use
contains gr. liu.
" Wellcome " Brand Anaesthetics. — Burroughs, Wellcome
& Co., London. It is well known that chloroform is subject to
decomposition by the action of air and ordinary daylight. To
Digitized by VjOOQIC
28o NOTES ON PREPARATIONS FOR THE SICK.
avoid all possibility of deterioration from such influences^
" Wellcome " Brand Chloroform is issued in hermetically-sealed
amber-coloured glass tubes.
" Wellcome *' Brand Ether, S.G. 720, which conforms to the
requirements of the British Pharmacopoeia for pure ether, is also
issued in hermetically-sealed glass tubes. By this method per-
fectly fresh and chemically pure anaesthetics are always available.
Nutritive Liquid Peptone with Creosote. — Parke, Davis & Co.,.
London. — ^This is described as a nutritive liquid, containing
peptone and the digested nutritive constituents of malt.
As there are various preparations of peptone on the market, an
analysis of the above was made in order to verify the statements
concerning it.
We consider it to be one of the best of its kind, especially as it
contains nearly 20 per cent, of solid matter, and therefore is more
than a simple stimulant. It contains non-coagulable proteid,
together with extract of malt. On distilling the liquid, a little
alcohol passed over, probably added as a preservative.
It possesses a pleasant flavour, and is altogether an attractive
preparation. The combination with creosote and guaiacol
(nutritive liquid peptone with creosote) should be very useful and
acceptable to patients with chronic lung diseases.
Triple Glycerophosphates with Nuclein (Chocolate-coated
tablets). — Parke, Davis & Co. — These tablets provide the tonic,
nutritive and reconstructive properties of the glycerophosphates
in association with the bactericidal, action of nuclein. Nuclein, it
will be remembered, also possesses the valuable power of in-
creasing leucocytosis. This combination is valuable in debilitated
conditions generally, and particularly in the various manifesta-
tions of tubercular disease, as scrofula, abscess, lupus, adenitis,
ulcers and phthisis.
No. 509 Compressed Tablets, Phenol-Phthalein Compound.—
Parke, Davis & Co. — Each of these tablets contains i grain of
phenol-phthalein, ^u grain strychnine sulphate, and tJit grain of
extract of belladonna leaves. The laxative effect of phenol-
phthalein is well known ; it is reputed to be particularly well
adapted for use in habitual constipation, acting without pain or
tenesmus. The strychnine and belladonna are valuable auxili-
aries, giving tone to the intestinal tract and restoring natural
function. The sugar-coated tablet is a particularly acceptable
as well as convenient mode of prescribing these drugs. The
dose for adults is from three to five tablets at bed-time ; for
children and delicate women, from one to three tablets will be
sufficient.
Digitized by VjOOQIC
NOTES ON PREPARATIONS FOR THE SICK. 28r
lodalbin. — Parke, Davis & Co. — lodalbin is an iodo-proteid
compound containing 21 to 25 per cent, of iodine. It is in the form
of an almost tastdess powder, insoluble in water, acids or alcohol,,
but readily soluble in alkahne solutions. When administered, it
passes unchanged through the stomach, and is gradually absorbed
in the intestine, thus avoiding the gastric irritation that the
alkaline iodides are liable to excite, and also ensuring a milder
systemic effect. Experiments on animals show the presence of
iodine in the saliva very shortly after its administration, but very
little can be traced in the faeces. Several months of close clinical
observation demonstrate that iodalbin produces the typical
alterative effect of the organic iodides without their disadvantages,
lodalbin may therefore be advantageously ^Drescribed in preference
to the alkaline iodides in all cases where such treatment is in-
dicated. A smaller dose, 5 to 10 grains, is sufficient, though
many patients have taken as much as 60 grains per diem without
untoward effects.
Adrenalin and Eucaine tablets. — Parke, Davis & Co. — ^Con-^
siderable attention is now being given to local analgesia, as
preferable in many cases to total anaesthesia, and for this purpose
" Eudrenine " is daily being more and more used. For medical
men abroad and for those who prefer to make their own
solution at the time of operating, these tablets of Adrenalin and
Eucaine have been introduced. Each contains Wtttt grain of
adrenalin and i grain of eucaine lactate, with a proportion of
sodium chloride sufficient to impart salinity to the solution. One
tablet dissolved in 17 minims of sterile distilled water forms an
analgesic and ischaemic agent for use in dental extractions and
small operations, containing i per cent, of the eucaine salt and
about I of adrenalin in 30,000 parts. One tablet, dissolved
in 85 minims of sterile distilled water forms a solution similar
in strength to that used in operations at University College
Hospital, as reported in The Lancet, July 25th, 1903, and The
British Medical Journal, December 24th, 1904.
Formidine. — Parke, Davis & Co. — Formidine is a potent
antiseptic suitable for internal or external use. Chemically it is
methylene disalicylic acid iodide, a condensation product of iodine,
formic aldehyde, and salicylic acid. It is insoluble in water,,
alcohol and dilute acids. In contact with alkaline organic
secretions, it slowly dissolves and develops the characteristic
germicidal properties of its constituents, hence it is most useful
for bacterial infections of the intestinal tract. The dose is from
I to 5 grains. Externally it is used in place of iodoform as a
stimulating, non-irritating dressing for wounds, ulcers, &c., and
as a dusting powder for vaiious skin affections. Its antiseptic
Digitized by VjOOQIC
282 NOTES ON PREPARATIONS FOR THE SICK.
power has been proved to be greater than that of iodoform,
whilst it is free from offensive odour, does not stain the skin or
olothing, does not irritate, and does not produce toxic effects
when applied over large areas.
Tannigen has been found particularly useful in infantile
diarrhcea. Tannigen is an odourless and tasteless preparation.
The fact that it passes unchanged through the stomach, and is
not decomposed into tannic acid until it reaches the intestinal
canal, renders it of great value in gastro-intestinal affections.
Dose : For adults, up to 15 grains ; children, 2 — 5 grains, in
milk, as frequently as the occasion may require. A convenient
way of administering Tannigen is the tablet form.
Tilia. — Peek, Frean & Co., London. — ^Tiha is a name given
to a milk proteid manufactured by Peek, Frean and Co.
It is a white powder, almost tasteless and odourless, and gives
the characteristic proteid reactions when examined chemically.
As a food accessory milk proteids are extremely valuable,
being very rich in nitrogen, and readily digested and assimilated.
In addition to Tilia in the form of a powder, Peek, Frean and
Co. have put on the market various products containing Tilia,
such as cocoa and various kinds of biscuits, to which the intro-
duction of a large percentage of the proteid is guaranteed.
We examined several of these with satisfactory results, but
consider the *' Diabetic Biscuits " deserving of special notice.
They are starch and sugar free, and when placed on a dilute solu-
tion of iodine show not the slightest blue colouration — a very
delicate test, showing the absence of starch.
We are pleased to speak highly of these preparations.
Pertussin. — E. Taeschner, Berlin. — ^This preparation is a
saccharated elixir, which contains as the chief active ingredient
essential oil of thyme. It is recommended for whooping-cough,
asthma, catarrh of the larynx, &c. It is not unpleasant to take,
and acts as a fairly powerful expectorant.
It is doubtful whether the use of such proprietary articles as
this can be justified when so many well-known and approved
remedies, prepared from published formulae, are at the disposal
of the physician.
Grape Nuts. — Grape Nuts Co., Shoe Lane, London, E.G.—
During recent years grape nuts have been much advertised as a
food.
An analysis of the preparation reveals the presence of proteids
Digitized by VjOOQIC
LIBRARY. 283
and soluble carbohydrates (dextrin and reducing sugars), which
have been derived from the starch present in the cereals used in
the manufacture. Some of the starch has remained unchanged
during the preparation of grape nuts: this we consider an
advantage for most people.
Claroma : Catarrh Scent. — J. M. Bannerman, Edinburgh. —
This inhalant for catarrh is a germicide remedy, a concentrated
solution of antiseptics with essential oils. It is free from cocaine
and opiates, and it produces a cool, soothing sensation which seems
to free the breathing, arrest discharge and sneezing, and give relief
to the pain and fulness of the head.
Tablets. — ^The Bayer Company Limited, St. Dunstan's Hill,
London.
Aspirin.
Helmitol.
Heroin Hydrochl. (gr. ^V)-
Tannigen.
Trional-Bayer.
Veronal.
Many of the special preparations of this firm are now issued in
five-grain tablets. We have received specimens of the above-
named. They represent a convenient and handy mode of ad-
ministration of drugs which are becoming increasingly useful.
The tablets are of the highest quality, and they readily dis-
integrate.
For the chemical analyses mentioned in the above report
we have to thank Mr. O. C. M. Davis, B.Sc, A.LC, of the
University College Laboratory.
XTbe Xibrari? of tbe
JSristol jflDe&ico-'CbirurQical Societi?*
The following donations have been received since the publication
of the List in June :
August 315^, 1907.
L. M. Griffiths (i) . . i volume.
Middlesex Hospital (2) i
R. Shingleton Smith, M.D. (3) 5 volumes.
Unbound periodicals have been received from Dr. Shingleton
Smith, and pamphlets have been presented by Mr. L. M. Griffiths.
Digitized by VjOOQIC
284
LIBRARY.
SIXTY-FIFTH LIST OF BOOKS.
The titles of books mentioned in previous Hsts are not repeated.
The figures in brackets refer to the figures after the names of the donors
and show by whom the volumes were presented. The books to which no
such figures are attached have either been bought from the Library Fund,
or received through the Journal,
Adamson, H. G. .. Skin Affections of Childhood 1907
Ballanee, C. A. . . Some Points in the Surgery of the Brain . . 1907
Barwelly H Diseases of the Larynx 1907
Bennle, P. B. .. Treatment of Hip Disease 1907
Budln, P The Nursling. (Tr. by W. J. Maloney) . . 1907
Campbell, H. ..On Treatment 1907
Ehrllehy P Collected Studies on Immunity. (Tr. by
C. Bolduan)
Functional Nervous Disorders in Childhood
1906
1907
1907
1907
1832
Guthrie, L. G.
Horsley and Mary D. Sturge, Sir V. Alcohol and the Human Body
Janet, P The Major Symptoms of Hysteria
Johnson, J Change of Air (i) 3rd Ed.
Lowe, P. . . . . A Discourse on the Whole Art of Chyrurgery
(3) 4th Ed. 1654
Luff, A. P Gout 3rd Ed. 1907
Madden, F. C. Bilharziosis 1907
Maddox, E. E. Ophthalmological Prisms 5th Ed. 1907
Miles, A. Thomson and A. Manual of Surgery Vol. II. 2nd Ed. 1907
Murrell, W. . . What to do in Cases of Poisoning loth Ed. 1907
Oppenhelmer, C. . . Toxines and Anti-Toxines. (Tr. by C. A.
Mitchell) 1906
Osier, W The Growth of Truth (3) 1907
Pharmacopoeia of the Bristol Royal Hospital for Sick Children and
Women 1907
Poynton, F. J. . . Heart Disease and Thoracic Aneurysm . . 1907
Sargent, P Surgical Emergencies 1907
Scott, H. H Post-Graduate Clinical Studies. ist Ser. 1907
Starling, E. H. . . The Croonian Lectures (3) 1905
Startln, J. (Ed.) . . A Skin Pharmacopoeia 6th Ed. 1907
Steell, G. . . . . Diseases of the Heart 1907
Sturge, Sir V. Horsley and Mary D. Alcohol and the Human Body 1907
Sutherland, G. A. Treatment of Disease in Children 1907
Sylvius, F. de la B. Praxeos Medicce . . . . (3) Editio altera 1672
Thomson and A. Miles, A. Manual of Surgery. Vol. II. 2nd Ed. 1907
TRANSACTIONS, REPORTS. JOURNALS, &c.
American Dermatological Association, Transactions of the . . . . 1906'
American Journal of Ophthalmology, The . . . . Vol. XXIII. 190^
Archives of Neurology Vols. II., III. 1903-07
Digitized by VjOOQIC
MEETINGS OF SOCIETIES. 285
Archives of the Middlesex Hospital (2) Vol. IX. 1907
Bader-Almanach (3) 1907
Bristol Port Sanitary District. Annual Report of the Medical
Officers of the, 1906 1907
British Medical Journal. The Vol. I. for 1907
Clinical Journal, The Vol. XXIX. 1907
Edinburgh Medical Journal, The . . . . N.S., Vol. XXI. 1907
English Catalogue of Books. The, for 1906 1907
Hospitals —
St. Thomas's Hospital Reports Vol. XXXIV. 1906
Westminster Hospital Reports Vol. XV. 1907
Journal of Laryngology, The Vol. XXI. 1906
Journal of Medical Research, The Vol. XV. 1906
Lancet, The Vol. I. for 1907
Library Association Record, The Vol. VIII. 1906
Munchener medizinische Wochenschrift Bd. I. 1907
Obstetrical Transactions Vol. XLVIII. 1907
Progressive Medicine Vol. II. 1907
MEETINGS OF SOCIETIES.
3Bristol jflDe&ico::»Cbiruraical Society*
June 12th, 1907, at Weston-super-Mare.
Mr. James Taylor, President, in the Chair.
Dr. Charles and Prof. Walker Hall showed specimens from
a case of Carcinoma of the Stomach.
Dr. H. Stanley Ballance showed a female patient upon
whom Estlander's Operation for Empyema had been successfully
performed. The following is the history of the case in brief : —
Mrs. B.,aet. 45, first became ill in October, 1901. On July 27th,
1902, the left side was found to be almost motionless during
respiration ; there were signs of a large amount of fluid ; the
temperature was 103°. Part of the 9th rib in the posterior axillary
line was removed, and a good deal of pus evacuated. One month
later part of the 8th rib was removed, and a second and smaller
pus-containing cavity opened. On February 6th, 1904, a probe
could be passed upwards to the level of the ist rib ; parts of the
5th, 6th, 7th, 8th and 9th ribs, with intervening soft parts and
parietal pleura, were removed. On February 27th, 1904, parts of
Digitized by VjOOQIC
286 MEETINGS OF SOCIETIES.
the 2nd, 3rd and 4th ribs were similarly removed. Eleven days
later symptoms of acute pericarditis appeared, but passed off
rapidly on administering antistreptococcus serum. The patient
improved until the following July, and then for 3 J months was
melancholic. The wound is now healed, and the patient living
her ordinary life.
Dr. Roxburgh read a paper on a case of Banti's Disease with
Complications. The patient (female), aged 48, presented
symptoms of extreme anaemia, slight dilatation of the heart,
enlargement of spleen and liver, a hectic temperature and deficient
air entry, with crepitations in the left upper and right middle
pulmonary lobes. These conditions had begun three months
before admission (though dyspnoea on exertion had been observed
two years earlier). On admission the liver reached 2^ inches
below the right costal margin, and the spleen, which was peculiarly
hard to the sense of touch, projected two finger breadths below
the left costal edge. The blood count was erythrocytes, 2,320,000 ;
leucocytes, 6,316 ; no poikilocytes ; haemoglobin decidedly
diminished. In twenty-three days these figures had fallen
respectively to 1,111,000 and 4,900 ; general pigmentation of the
skin had become marked ; and pulmonary signs more pronounced,
including whispering pectoriloquy at the left apex. No tubercle
bacilli were found in the scanty sputum. The spleen had in-
creased in size, and the liver extended seven inches below the
costal margin. Five weeks after admission, the patient died, and
the autopsy showed, put very shortly : — Heart : Fatty degenera-
tion. Lungs : Right firmly adherent in most of its extent to the
thoracic wall and diaphragm ; both lungs in a state of fibrous
cirrhosis, the result of chronic interstitial pneumonia ; no bron-
chiectasis, no caseation or tubercles. Bronchial glands large,
hard, and black, as in anthracosis, but not tubercular. Spleen :
7.5 inches in length, tough and hard, with thickened capsule, on
section fibrous ; Malpighian bodies indefinite. Liver : Peculiarly
formed, the right lobe extending almost to the iliac crest ; the
whole organ very firm and tense, in a state of fine cirrhosis with
fatty degeneration. Kidneys and supra-renals normal. No
tubercle of mesenteric glands, but the mesentery dotted with
small black spots, probably former petechias. Microscopically,
the extreme fibrosis of spleen, liver and lymphatic glands was
confirmed. These irritative changes and the train of symptoms
leading directly to death, pointed to some such chronic intoxica-
tion as that which presumably occurs in Banti's disease ; but in
the course of that syndrome the splenomegaly seems to precede
the anaemia and enlargement of liver, sometimes by several years.
In the absence of a complete history it was impossible to say
whether such had been the case here. The chronic interstitial
changes in the lungs may have been due directly (or indirectly,
following a chronic interstitial inflammation) to the same toxin.
Digitized by VjOOQIC
LOCAL MEDICAL NOTES. 287
Dr. Armstrong's paper at last year's Toronto meeting of the
British Medical Association gave an excellent resume of the subject
and a complete list of all the cases of Banti's disease up to that
date treated by excision of the spleen. This list comprised 32
cases, with 23 recoveries, i.e. 72%. Dr. Armstrong concluded
(i) that the disease is essentially progressive ; (2) that no treat-^
ment other than splenectomy is permanently effective in removing
the anaemia and hindering the hepatic cirrhosis ; and (3) that
even in advanced cases the operation is followed by immediate
improvement, which often has a considerable amount of per-
manency. He laid special stress on the dilatation of the splenic
vein, and even suggested that a primary endophlebitis of that
vessel might set up the disease by causing backward pressure,
injury to the vitality of the spleen pulp, and consequent produc-^
tion of an enzyme, which acted as a toxin to the liver. This was
as yet purely theoretical, and the primary cause of the spleno-
megaly still remained obscure. — Dr. Roxburgh's paper was
criticised by Dr. Edgeworth and Dr. Michell Clarke. The
former doubted whether the case properly should be classed as
Banti's disease. The latter admitted the complexity of the case,
and the great difficulty of its diagnosis. — Dr. Roxburgh, in reply,
affirmed his belief in the splenic origin of the symptom complex,,
while the pulmonary cirrhosis was probably an after effect, like
the Hanot*s cirrhosis of the liver, which was so constant.
Dr. Crouch read a paper on a suggested Treatment for Func-
tional Aphonia. (For this paper see p. 214.)
Dr. Michell Clarke read a paper on the Treatment of Graves's
Disease. (Vide p. 201.)
J. Lacy Firth.
H. F. Mole, Hon. Sec.
Xocal fRebical IRotea*
University College, Bristol. — Examination Results : —
M.B. LoND. — Intermediate Examination : P. J. Veale
F.R.C.S. — Primary Examination : E. A. Dorrell.
Conjoint Board. — Practical Pharmacy: H. H. Hiley, V.
Pinnock. Chemistry and Physics : H. B. Logan, G. H. Pien y,
W. Worger, B. G. Derry, A. G. T. Fisher. Anatomy and Physio-
logy : G. H. Griffiths, W. A. Reynolds, M. M. Lopez, R. S. S
Statham, H. R. B. Hull. Medicine : F. T. Boucher, A. E |Iles*,
Surgery : F. S. Scott.
* Completes Examination.
Digitized by VjOOQIC
-288 LOCAL MEDICAL NOTES.
L.D.S. Eng. — Chemistry and Physics: L. J. Kinnersley,
J. D. Melhiiish. Physics only : G. Smith.
Indian Medical Service. — At the recent examination for
appointments in the Indian Medical Service, three students of
University College, Bristol, were successful. Mr. V. B. Green-
Armytage gaining second place, with 3,834 marks ; Mr. Francis
Shingleton Smith, M.B. Cantab., tenth place, with 3,410 marks;
and Mr. A. N. Thomas, fourteenth place, with 3,283 marks.
There were thirty-four candidates for the examination, and of
these twenty-seven qualified to sit for the examination.
Dental Department. — It is now possible for students to
undertake their Mechanical Dentistry and Metallurgy on the
College premises, where laboratories have been fitted out with
all the latest apparati for this purpose. The composition fee
for the entire curriculum, including Hospital practice and two
years' mechanical work in the laboratory, is 140 guineas.
The following appointments have recently been made : — Carey
F. Coombs, M.D., B.S. Lond., Demonstrator in Dental Bacteri-
ology ; E. A. G. Dowling, L.R.C.P., M.R.C.S., L.D.S., Lecturer in
Dental Anatomy, Physiology, and Dental Histology ; Frederick
W. Perry, L.D.S. , Demonstrator in Dental Anatomy, Physiology
and Dental Histology ; J. W. McBain, M.A., Lecturer in Dental
Metallurgy and Practical Dental Metallurgy ; Reginald Davis,
Instructor in Dental Mechanics; W. J. Lennox, L.D.S. Eng,
Honorary Demonstrator in Physiology.
Admission of Women Students to MediCal Department.
— We understand that the Council of the College has undertaken
the important step of admitting women to the full medical
curriculum. Previously they had been allowed to attend certain
lectures, but this privilege had not to any great extent been taken
advantage of. The rules now admit them to the whole course
on exactly the same footing as men.
Bristol General Hospital.— J. Odery Symes, M.D. Lond., has
been appointed ^ Physician, and Carey F. Coombs, M.D. Lond.,
has been appointed Assistant Physician.
Dr. John Beddoe. — An interesting ceremony took place
recently at the Bristol Art Gsdlery, when a portrait of Dr. Beddoe,
by Miss Wren, was handed over to the chairman of the Museum
Committee for hanging in the Bristol Room. It had been sub-
scribed for by Dr. Beddoe's friends and admirers, who wished to
have some permanent momento of this great ethnologist, who had
lived and worked in the city for so many years. Dr. Beddoe, who
was present, thanked the speakers for their kind expressions of
affection.
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^be Bristol
fllbebico^Cbivurgical JournaL
*' Scire est nescire, nisi id me
Scire alius scireC
DECEMBER, I907.
SYPHILIS.
tCbe prcdibential Bd&re00, beUvereb on October 9tb, W07t at tbe opening of tbe
UbirtT'sfourtb Seseion of tbe JSnetol AedicosCbirurgical Society.
BY
Henry Waldo, M.D.,
Consulting Physician to the Bristol Rcyal Infirmary,
First of all I wish to renew my cordial thanks to you for electing
me as your president. In searching for a suitable subject for
an address, it occurred to me that syphilology Jiad made great
strides during recent years, chiefly owing to the discovery of the
spirochaeta pallida. Syphilis is truly called the imitator of very
many other diseases. It is also one of the oldest, if not the oldest
disease which has afflicted mankind. In Fournier's recent work
on syphilis the author regards this disease as such a common
cause of miscarriage, that he considers that syphilis is one of the
chief factors in the causation of the present depopulation of
France. I scarcely know what the staff of a hospital would find
to do if syphiUs in its different phases were eradicated. It
offers many obscure clinical cases for investigation, and when
20
Vol. XXV. No. 98. Digitized by Google
290 DR. HENRY WALDO
recognised, it is one of the most satisfactory conditions to treat.
One of our members told the City Council that sanitation was
rapidly interfering with the gold mine of medicine. I think that
if syphilitics were no more the mine might be closed down. The
opinion seems to be gaining ground that syphilis is absolutely
curable, excepting when it is associated with the abuse of alcohol.
It was Moxon, I think, who said that spirit is the best
preservative of syphilis. Its curability is borne out by the
following facts.
It used to be taught that syphilis could only be acquired
once in a lifetime, and that reinfection was inlpossible ; but a
number of cases have been recorded by careful observers which
seem to establish the possibility of reinfection bej^ond a doubt.
Hutchinson has observed two cases, in one of which the patient
passed through two attacks of primary and secondary syphilis,
with an interval of five years. In the second case the patient
had three attacks, with intervals of fourteen and nine years.
Berkeley Hill relates the case of a surgeon who acquired syphilis
in the usual way ; eleven years later he contracted a digital
chancre, followed by secondary syphilis. It is interesting to
note that Ricord in his later years recognised the possibility of
reinfection. In a letter to W. Acton in 1872, he said : " Now
that we have authentic examples of fresh contagions of indurated
chancres, with consecutive evolution of the whole series of
constitutional symptoms, this proves that patients have been
cured, just as the possibility of contracting small-pox afresh, or
of vaccination again taking, proves that the first variolous or
vaccine influence had ceased." Sir William Gowers has been
reputed to have made the statement : *' Once a S5^hilitic,
always a syphilitic." But when he was asked to give his
reasons for this at a medical meeting, he said : "I have never
said such a thing, I have never thought such a thing." He
believed every syphilitic ultimately ceases to be a syphilitic,
and he continued : *' So far from being a sceptic as to
therapeutics, I would say this, that you could bring syphilis
to an end in the kingdom if you kept under the influence of
mercury every unmarried man between 18 and 50 years of age
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ON SYPHILIS. 291
continuously But,** he added, " you would extinguish other
things besides S5^hilis. Promotion in the army would become
mysteriously rapid, and the members of the House of Lords
would gradually melt away. But/* said Sir William, '* I am not
sure that such a price would be too high to pay for such a boon.
That is,** he said, "a matter of opinion. We all know Mr.
Jonathan Hutchinson*s view, namely that he believes that
mercury is an antidote to the syphilitic poison if properly
administered.**
The parasitic germ of syphilis was discovered by Fritz
Schaudinn two years ago (1905), and named the spirochaeta
pallida. It was called pallida on account of the physical
properties of the germ possessing a low power of refracting
bght. Maclennan regards the spirochaete as only one stage in
the life histor\' of the micro-organism of syphilis. Unfortunately,
a few months after his discovery Schaudinn died, at the early
age of 35.
We as a profession are immensely indebted to men like
Schaudinn, who devote their lives to work in their clinical
laboratories, who as a rule are miserably paid, and who are
not recognised in anything like the way they should be.
They may console themselves in the words of Emerson, that
" a man was born not for prosperity, but to suffer for the benefit
of others.** I am sure we all agree with the views of Mayo
Robson, that there should be a closer union between the work
of clinicians and pathologists. We do not make all the use we
might of pathological investigation to aid our clinical observations.
He thinks the deep debt that preventive medicine owes to
bacteriology is likely to be equalled, or even excelled, in the
realm of treatment ; for not only have bacteriologists shown us
how to treat infectious diseases, such as diphtheria, by antitoxic
serums, but we have had demonstrated to us recently how the
tissues can be rendered immune to various infective agents by
inoculation, under suitable conditions that can be determined by
the method of blood examination devised by Sir A. E. Wright.
Robson says the chemistry of the body is as yet in its infancy,
but it has a great future before it. He advocates that investiga-
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292 DR. HENRY WALDO
tions of a private nature, not involving public health questions,
should be conducted at the expense of the individual requiring
them ; and in those of a more difi&cult and complicated character,
especially when the clinical diagnosis depends on the result of
the pathological findings, it seems 'to him desirable that the
pathologist should be met in consultation. While it seemed
most desirable that poor patients should not be deprived of the
help afforded by pathology, yet it seemed anything but desirable
that wealthy or well-to-do patients should be paying adequate
fees to their medical or surgical advisers and a mere pittance
to the pathologist, on whose findings may hang very vital issues.
Well, gentlemen, we are all looking forward in the hope that
this important discovery of the spirochaeta pallida will assist us
in treating patients who may be supposed to be syphilitic. It
has long been debated whether it is wise to administer
mercury to a person with a primary sore, or to wait for
confirmatory symptoms. Marshall says (in Syphilology and
Venereal Disease, 1906) none of the attempts at abortive treat-
ment by destruction or excision of the chancre have been
definitely successful. The chancre has been excised a few hours
after its appearance, the lymphatic glands have been removed,
an abrasion has even been excised before any chancre appeared,
but all these measures have failed to prevent the development
of constitutional syphilis.
The failure of these abortive methods is due to the fact that
syphilitic infection of the system takes place very rapidly, both
by the lymphatics and blood vessels. When the chancre appears
the organism is already entirely infected, or, at any rate, the
infection has extended over an area too large for any form of
excision to be effectual.
The recent experiments of Metchnikoff , 1 however, seem to
show that syphilitic infection may be prevented by early
inunction of the point of inoculation with an ointment containing
from 25 per cent, to 33 per cent, of calomel. After establishing
this fact by a series of experiments on monkeys, the experiment
was tried on a medical student who volunteered for the purpose.
1 Brit. M. /., 1906, ii. 15 10.
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ON SYPHILIS. 293
Syphilitic vims from two chancres was inoculated by scarifica-
tions in the balano-preputial furrow ; at the same time four
macacus monkeys were inoculated with the same virus. An
hour after inoculation calomel ointment was rubbed into the
scarifications for eight minutes in the student and in one of the
monkeys. Twenty hours afterwards the same treatment was
applied to another monkey. The two remaining monkeys were
kept for control, and developed syphilitic chancres seventeen
days after inoculation. The monkey treated twenty hours after
inoculation developed a chancre on the thirty-second day. No
sign of syphilis appeared in the student, nor in the monkey treated
at the same time, up to three months after the experiment.
As Marshall points out, these experiments may require further
confirmation, yet they tend to show that syphilis may be
prevented by mercurial inunction of the point of inoculation an
hour after infection. But he thinks the practical application of
this discovery is limited, owing to the fact that the point of
inoculation is not known with certainty unless there is an
abrasion. Moreover, patients seldom apply for treatment
within an hour of possible infection. However, if such a case
presents itself, inunction with calomel ointment at the supposed
point of inoculation is indicated. Pernet saysi that every medical
man, dental surgeon and midwife, liable as they are to
accidental infection, should have a pot or tube of it handy in
case of need, so as to apply it with as little delay as possible.
Marshall, in the following week's Journal, suggests that the
ointment should be applied before the event.
Jonathan Hutchinson says the earlier mercurial treatment is
begun the better, provided the diagnosis is certain. He also
thinks that many chancres are sufficiently characterised to
justify immediate treatment. We should all agree, I think,
that as mercurial treatment, to be effectual, must extend over
rather long periods, it is a serious and unjustifiable proceeding
to commence treatment until we are certain of what we have to
treat. And if the pathologist can assure us of the presence of
the parasitic germ, it must be of the greatest advantage ; for
1 Brit. M. J., 1907, i. 730.
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294 DR. HENRY WALDO
although this organism has not at present been cultivated, and
cannot, therefore, fulfil the postulates of Koch to prove its
pathogenic nature, it has been found sufficiently frequently in
syphilitic lesions to justify the assumption that it is the specific
microbe of syphilis.
In the case of chancres a doubtful diagnosis may be cleared
up by finding the spirochaeta in the exudation. It has been found
almost constantly in the primary and secondary lesions of
syphilis, not only on the surface of ulcerated lesions, but also in
non-ulcerated lesions, such as papules and lymphatic glands,
and in the viscera. It has also been found in the blood (although
rarely). Several recent observations considerably modify various
previous conceptions with regard to the disease: for example,
the discovery of the microbe in gummata, showing that the
gumma might be contagious , the fact that Levaditi has detected
the spirochaete in the renal epithelium and various other organs
in congenital syphilis, showing that the normal secretions, such
as the urine, may be contagious.
The spirochaete has not been found in men or monkeys apart
from syphilitic lesions. The reason why it has not been observed
before in syphilitic lesions is explained by the difficulty in
technique, and also by the fact that it is not always found.
Metchnikoff failed to find it in 26 per cent, of the cases he
examined. The London men tell me they have the very greatest
difficulty in finding it. Thus a negative examination does not
prove that a lesion is non-syphilitic, any more than the absence
of the tubercle bacillus in lupus negatives the tuberculous nature
of this affection. Levy Bing has shown that the spirochaeta
pallida rapidly disappears under the influence of mercury. Six
or seven days after an injection of gray oil they became scarce,
and a week after the second injection they had almost
disappeared. Kowalewski, after demonstrating their presence,
noted their disappearance after six injections of sublimate.
In the British Medical Journal for i6th June, 1906, Dr. W. R.
Grove, of St. Ives, Huntingdonshire, gives brief histories of three
cases of syphilis, presumably acquired from a baby 18 months
old, with the inherited complaint. In each case the site of
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ON SYPHILIS. 295
infection was believed to be the tonsil. A leading article
appeared in the same journal saying that the view that the
power of infection in inherited syphilis was much exaggerated
by writers in the past is very widely held nowadays, and dis-
crediting the belief that inherited syphilis is infectious. At any
rate, in the light of more recent knowledge, the editor thought
many would now consider the evidence as insufficient. In the
following week's Journal a letter appears from Mr. Jonathan
Hutchinson, in which he says that he has read Dr. Grove's
communication with much interest, and also the editor's comments
on it not without amazement. He had supposed that the
contagiousness of inherited syphilis in infants was a fact about
which no controversy was possible. He said it was, as all knew,
in order to explain cases in which exposure to risk occurred without
ill result that Colles formulated the law now known by his name.
Mr. Hutchinson says he is quite in the dark as to what the
^' more recent knowledge " referred to may be. The only more
recent knowledge with which he is acquainted is that which
concerns the spirochaete, and this he considers is entirely
confirmatory of his conclusions, as this parasite has been found
repeatedly in the early lesions of inherited syphilis, and he says
that as it is now held to be the efficient agent in contagion, it is
difl&cult not to consider its presence as proof that this form of
the malady may be communicable. Primary infection of the
tonsil in connection with the feeding of this class of infants has
been witnessed repeatedly. Mr. Hutchinson reminds his readers
that not so very long ago one of our associates had to pay a
considerable sum to a wet-nurse whom he had inadvertently
permitted to suckle an infant suffering from syphilis, which was
believed to have been inherited. He concludes by saying that
he must hold that to propound unsupported doubts involves
not only a very foolish heresy, but a very dangerous one ; and
he much regrets that it should seem to have received in any
degree the support of the editorial pen of the British Medical
Journal,
Some years ago I was asked by a lady to attend her in her
first confinement. This I was obliged to decline, as there is
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296 DR. HENRY WALDO
a rule at our Infirmary prohibiting a physician from practising^
midwifery, and so the patient was passed on to a medical friend.
Some little time after the birth of the child the mother consulted
me for an eruption on her fingers which much resembled scabies^
although it did not itch. After a little interrogation as to whether
she was able to suckle her baby she said, " Oh, yes ! " but that it was
rather painful on account of the nipple being sore. After examin-
ing this sore, I came to the conclusion that it was of the nature
of a chancre, and that the child was the subject of congenital
syphilis. They were both very amenable to treatment, but after
a time the child developed a large liver, in all probability
lardaceous disease, and died with dropsical s5miptoms and other
signs of congenital sj^hilis. Well, this case was clearly an
exception to what is known as CoUes's law, and I have often
intended to publish it. It was in 1837 ^^^^ Colles, of Dublin,
pointed out that the mother of a S5^hilitic infant, procreated
by a syphilitic father, was herself immune against infection, and
could suckle her child with impunity ; while a healthy wet-nurse
(^ould contract a chancre of the nipple by suckling the same child.
Since this time other well-authenticated cases of exception to this
law have been recorded, where mothers contracted chancres of
the nipple by suckling their syphilitic infants. Pemet saysi that
CoUes^s law is right; and that CoUes's law is a law I have
myself no doubt whatever. The alleged exceptions, he says, when
examined, cannot hold water. It is obvious, therefore, he
continues, that the mother should also be treated, especially
from the point of future pregnancies.
Upon inquiring into the history of the father in my case, I
found that he contracted syphilis in the usual way some years
before marriage, that the treatment he received was a mere
farce, and that he was addicted to alcohol, which has been well
called the bom enemy of syphilitics.
When may a syphilitic safely marry is a question which is not
easily answered. Mr. Hutchinson differs from most other
authorities in stating (as recently as June, 1906) that if the
treatment has been continued for two years from the date of
1 Brit, M, J., 1907, i. 734.
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ON SYPHILIS. 297
the chancre a man may safely marry, but that a much longer
period is necessary for a woman. He also remarked : ** I have
let hundreds of such patients marry, and they have never come
back to me in consequence of Raving infected their wives, or
having syphilitic children." Marshall thinks that this statement
cannot be accepted as evidence of the safety of the two years'
system, for, in case of failure, it is probable that the patients
would not come back. In this way, he adds, the successes are
recorded, but the failures unknown.
Fournier lays down the law that no syphilitic should marry
for at least three or four years after the onset of the disease,
and then only when the following conditions are fulfilled :
(i) absence of actual lesions ; (2) prolonged treatment ; (3) a
period of immunity from s5miptoms for at least one and a half to-
two years, during which time no treatment has been taken ;
(4) a benign type of disease. Fournier relates the history of
twenty cases of marriage in sj^philitics under two years ; nineteen
of the wives were infected, and there were twenty-eight ])regnan-
cies, resulting in thirteen abortions, six early deaths, six
syphilitic infants, and only three healthy children.
Ledermann says : " Generally speaking, marriage may be
allowed if at least five years have elapsed since the infection
took place, if no more manifestations have occurred during the
last two years, and if the patient has received an energetic and
thorough mercurial treatment."
Baltzer is of opinion that marriage may be allowed during
the fifth year, provided that the symptoms have been benign^
the treatment regularly followed, and that there have been no
symptoms during the fourth year. He also advises a course of
preventive treatment immediately before marriage, and during
the year following. In the case of a syphilitic woman, he says^
preventive treatment is required for a long time, because the
power of maternal transmission lasts much longer than that of
paternal heredity.
Marshall thinks that any arbitrary time-limit is both
dangerous and unscientific.
In referring to later forms of syphilis, a subject which resolves
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I2g8 DR. HENRY WALDO
itself into syphilitic disease of the arterial system, Darier says :
" To study sj^hilitic arteritis in its widest sense is to deal with
the whole pathology of syphilis." How many cases of so-called
cerebral hemorrhage, heart failure and the like are due to
syphilis. Arterial disease especially affects the arteries of the
brain and of the heart — possibly of the spinal cord — in the
earlier period, and accounts for general paralysis and tabes
dorsahs in the later period.
Ferrier suggests that the terms cerebral tabes, spinal tabes,
and cerebro - spinal tabes should be substituted for general
paralysis, locomotor ataxy, and tabo-paralysis.
Sir William Gowers says hemiplegia from specific arterial
disease is a malady in which we can make a confident pathological
•diagnosis from clinical facts. Every case, he says, of sudden
hemiplegia — sudden, and therefore of vascular origin — occurring
between the ages of i8 and 48, without Bright's disease, without
heart disease, in an individual who is known to have had syphilis,
may be confidently ascribed to syphilitic arterial disease. He
has been through the facts of forty cases of that kind, all
conforming to those conditions, and he finds that about one
quarter of them occur in the first two years after acquiring
syphilis, about one half in the first five years, nearly three-quarters
in the first seven years, four-fifths in the first ten years, and the
others are scattered over the next seven years. And as regards
surgical maladies, Marshall points out that syphilitic arteritis
affecting the vessels of the lower hmbs may lead to gangrene,
and cases of so-called ** senile gangrene," occurring in middle-
aged subjects, are now recognised by surgeons as usually due to
syphilis. Aneurism of the lower limbs, too, is frequently due
to the same cause. Or, again, effusion of fluid into a knee-
joint, with sub-acute symptoms only, is often syphilitic. It
differs from common rheumatism in only affecting one or two
joints, and exclusively the larger ones such as the knee, and in
the absence or transient nature of febrile S5miptoms. In
gonorrhceal arthritis the affection is more acute and painful,
and there is usually posterior urethritis present.
It is astonishing how authorities differ in regard to the
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ON SYPHILIS. 299
prognosis of late forms of syphilis. Pye-Smith says : *' I confess
I take a somewhat more favourable view of the outlook in cases
of tabes than Sir William Gowers does. Perhaps/' he says,
*' it is due to a smaller experience, but a few cases in which the
result has been favourable make a great impression upon one ;
and while agreeing with him," he adds, as I am afraid all of us
must as to the hopelessness of general paralysis, " I think cases
of tabes are much less formidable. They are not so common,
they last very much longer, often with long intervals of
improvement or, at all events, abatement of the disease, before
it is ultimately fatal. And sometimes — perhaps," he says, *' it
shows too sanguine a temperament — I have seen what looked
like favourable results from mercurial treatment in tabes/whereas
I do not think anybody has found such a result in general
paralysis."
Jonathan Hutchinson says (at almost the same time, 1906) :
*' Degenerative changes, such as tabes, are rarely arrested by
specifics. All conditions attended by inflammatory changes,
such as general paralysis of the insane, should be treated by sinall
doses of mercm-y continued permanently." In his belief, if
treatment of general paralysis be commenced in the very early
stage a cure may be obtained, but small doses of mercury must
be permanently continued. I have seen it stated that if some
of the inmates of lunatic asylums had blue ointment
regularly rubbed into their scalps there would be surprising
results.
Dr. G. H. Savage has somewhat recently pointed out^ that in
cases of general paralysis of the insane the memory was not
markedly affected. " Sometimes," he says, *' as in advanced stages
of general paralysis, there was a quite remarkable retention of
memory, whilst in other forms of progressive mental decay,
associated with alcoholism or senility, the loss of memory was
the chief characteristic." Dr. Savage has also mentioned that
among certain races — the Arabs and perhaps the Japanese —
syphilis may be frequent and general paralysis rare. He adds
that general paralysis was also said to be unknown amongst
1 Bfit. M, J., 1906, i. 1344.
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300 DR. HENRY WALDO
negroes and amongst the Irish. In his opinion syphilis required
something more in order to produce this disease — alcoholism,
worry and the stress of Hfe, and perhaps large meat
eating.
Widal has drawn attention to the fact that both in tabes and
general paralysis leucocytosis of the cerebro-spinal fluid was
constant and extremely well marked, the average being one
hundred and thirty in the field. He thinks the presence of this
leucocytosis is of great diagnostic importance ; for example, as
between tabes and peripheral neuritis, and between general
paralysis and epilepsy.
However, apart from general paralysis, it has been stated
that syphilis may cause all the common forms of insanity, from
the most violent mania to the most complete idiocy, and, as
Mott remarks, ** Of all the causes of insanity, none writes with
such a broad and indelible hand as syphilis." Barker says:
" Considering the predilection of syphilis for the nervous system,
it is remarkable that insanity is not more widespread than
it is."
Some few years ago I was consulted by a male patient
between 50 and 60 years of age for a sore throat. The tonsils
were red and swollen with the appearance of *' snail track,"
which is so suggestive of syphilis. There was also an
asymmetrical palmar psoriasis with affection of the nails. After
taking mercury for some time I sent him to see Mr. Hutchinson,
who advised me to continue with the same treatment for six
months. This advice was carried out very irregularly, and in
addition to this drawback the patient was addicted to the
alcoholic habit. After this he rather suddenly developed
delusional insanity, was most restless and difficult to manage.
I took ordinary precautions, and put him on gradually increasing
doses of iodide, and rubbed in five per cent, oleate of mercury.
Later on his relatives thought that he should be certified, but I
could see that he was improving, and he very soon made a com-
plete recovery. If I had not happened to know that this patient
was syphilitic I do not think it would have occurred to me that
he was the subject of syphilitic insanity. Whether this was a
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ON SYPHILIS. 301
case of early general paralysis cut short by treatment I am 'not
sure.
One day a male patient about 30 years of age came to see
me on his bicycle. He was exceedingly breathless, and could
scarcely speak. Upon examining his chest I discovered that he
had an aortic aneurism, and that one of his vocal cords was not
acting owing to pressure on the recurrent laryngeal nerve. I
advised him to go home to bed, and wait there till I came on the
following day. I induced him to stay in bed for about three
months, during the whole of which time he was taking rather
large doses of iodide, and the improvement was very marked.
About this time his children were being attended by their family
doctor, and he asked this gentleman to examine his aneurism,
and the opinion given was that he could not detect an
aneurism at all. This doctor, however, suggested that Dr.
Michell Clarke should meet him in consultation, and then the
aneurism was found to be very much in evidence. After this
the patient put himself under the care of an American doctor,
who said that he quickly cured aneurism, and induced the patient
to believe that he had cured him. The patient then wrote to one
•of the Bristol daily papers abusing Dr. Clarke and myself, and
pointing out how very much English doctors were behind their
American brethren. Some time after this Dr. Cory asked me to
^e this same patient with him, and I found him in a condition
of acute mania. I thought that he would put his fist through
the window pane every moment. We at once certified him,
and he went to Fishponds Asylum, and I think it was through
the zeal of Mr. A. L. Flemming that the aneurismal specimen
found its way into our museimi at the Infirmary. I have often
regretted that I did not include mercury in the treatment when
I had him in bed ; perhaps the insanity might have been
thereby avoided'.
In all these nervous affections there is a simple and reliable
sign which is worth special attention in making a differential
■diagnosis. It is that the loss of pupillary reflex to light
•constitutes by itself a sign which is almost pathognomom'c of a
:syphilitic lesion of the nervous centres : the pupil is fixed.
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302 DR. HENRY WALDO
Thus the Argyll-Robertson pupil is not the only pupillary sign
of sj^hilis. For this help in diagnosis we are indebted to
Babinski and Charpentier.
Syphilis sometimes attacks the aorta, and prepares it for
aneurismal bulging. . It less often limits its attentions to the
aortic valves. Hale White says^ : '* As for valvular disease, the
aortic valves were rarely affected alone in rheumatism. There-
fore, cases of aortic without mitral disease might be attributed
to atheroma, or strain, or syphilis ; and in women, as strain was
rare, aortic disease was strong evidence of syphilis. The same
applied to aneurism.'*
Some few years ago Dr. Shingleton Smith asked me to see
a young woman in one of his wards at the Infirmary with symp-
toms somewhat resembling those of rheumatic fever. There
was a loud murmur over the base of the heart, the patient was
acutely ill, and seemed likely to do badly. Her symptoms did
not respond to salicylates. There was an eruption over the body
which was really the key to the situation. The condition had
already been recognised by Dr. Smith, and the aortitis, with the
other manifestations of syphilis, gave way to specific remedies,
the patient made a good recovery, and I think lost all signs of
the cardiac trouble, I may safely say, through the means of a
skilful diagnosis.
As regards eruptions on the skin, Norman Meachen thinks
that by cultivating the sense of touch it is possible to
recognise whether the rash is syphilitic or not. There is he
says a good deal of infiltration in a syphilitic eruption, and
they all, except the macular, give one the impression as if the
lesions were let into the skin, the whole structure of which seems
to participate in the morbid process, and not the epidermis alone
as in psoriasis, eczema, and most others.
The most inveterate case of syphilis I ever saw was in a
woman who attended pretty regularly at the Infirmary for
fifteen years. The disease expended itself chiefly on the face
and neck, and left extensive cicatrices. There was a good deal
of the intradermic form of . lenticular syphilide in this case,
which forms the atrophic papular syphilide by destruction of
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ON SYPHILIS. 303:
the elastic tissue of the dermis, causing depressions simulating,
lineae albicantes.
The eruption in this case was always controlled by iodides,,
but believing as I do that the disease is only scotched by these
remedies, and not killed, she consumed a large quantity of
mercury besides. I do not think she was an alcoholic, but she
was badly fed, and so carried out my instructions of taking a
quart of milk daily. She was also told to be in the open air as
much as possible, and to sleep with an open window. Latterly
I adopted the plan of intra-muscular injections of mercury, and
then handed her over to Dr. Nixon, who, I believe, continued this
mode of treatment. Hutchinson says intra-muscular injections
are very dangerous, excepting in the hands of the expert, and
should be wholly reserved for special conditions, chiefly in the
army. If salivation commences, he says, it cannot be stopped ex-
cept by excision of the portion of muscle containing the mercury.
This woman's husband became insane, and an inmate of the
Fishponds Asylum ; probably a subject of syphilitic insanity.
Barker thinks that the cause of malignant syphilis is doubtful ;
it has been attributed both to excessive virulence of the microbe,
and to secondary infection with other organisms. It would
appear, he says, more probable that it is due to the implantation
of the microbe on virgin soil, i.e. on persons whose ancestors have
been free from syphilis.
* Whether the treatment of syphilis shall be continuous as
advocated by Hutchinson, or intermittent as carried out by
Foumier, is a matter of opinion. No doubt that for a time
mercury increases the haemoglobin and the red corpuscles :
later on it diminishes them. This indicates that mercury
should only be given for short periods at a time, and lends
support to " the chronic intermittent treatment of Foumier."
There are many other diseased conditions which result from
the parasitic germ of syphilis, and more especially when it is
untreated in its early stages, often cases which are known as
Lues insontium and syphilis ignota. Byrom Bramwell remarks :
" Why is it that one man who drinks gets cirrhosis of the liver,
while another man who drinks does not ? Is it that the man who
Digitized by VjOOQIC
304 SYPHILIS.
-gets cirrhosis of the liver has had syphiUs ? " Or as he says in
other words, sj^hilis renders the connective and vascular tissues
of the liver more vulnerable to other exciting causes.
It is thought by some good authorities that syphiUs is the
cause of Bright 's disease. Huchard says : " Interstitial nephritis,
before becoming a disease of the kidney, is an affection of the
cardio-arterial system."
Barker thinks that as syphilis is essentially a disease which
affects the vascular system, it is rational to regard it as an
important factor in the causation of Bright's disease.
Professor Poirier saysi : " Everybody cannot have cancer of
the tongue ; two conditions are almost indispensable — you must
be a smoker or syphilitic ; and those who combine those two
conditions, especially the latter, run a much greater risk than
other people. Cancer of the tongue," he says, " might be called
the cancer of syphilitic smokers."
Professor Foumier^ finds that among one hundred and eighty-
four cases of cancer of the mouth seen in his private practice,
one hundred and fifty-five had decided syphilitic antecedents, a
proportion of at least eighty-four per cent. In the twenty-nine
other cases the antecedents were not given.
It has been suggested by Pernet that the spirochaeta pallida
swarms at night, and so may account for the nocturnal pains
of syphilis. In some cases of neuritis, and especially in sciatica,
if the pain is worse at night it is usually best relieved,
I think, by antisyphilitic remedies.
In conclusion, gentlemen, I should like to say that no one is
more conscious than myself of the shortcomings of this paper,
and I sincerely thank you for your kindness, attention and
patience. In the words of Faust: —
" Expression, graceful utterance is the first and best acquirement
of the orator. This do I feel, and feel my want of it."
Note. — Since the above address was written the cultivation
of the. spirochaetes has been carried out in the rabbit's eye
through five generations, and finally inoculation into the monkey
has produced syphilis.*
1 Brit, M. /., 1906, ii. 1668. « Ibid.
I » Bertarelli, Zentralb. fiir Bakt, 1906-7.
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SOME REMARKS ON SPINAL ANAESTHESIA.
AS BASED UPON THE PERSONAL OBSERVATION
OF THIRTY CASES.
BY
Ernest W. Hey Groves, M.S. Lqnd.. F.R.C.S.
Assistant-Surgeon, Bristol General Hospital.
So much has recently been said and written on this subject,
that I do not propose to attempt any review of the history and
literature, but merely to record certain points of interest and
difl&culty that have occurred in actual practice. It is only by
the noting of difficulties and drawbacks of any new method that
these may be met and eventually overcome. The operations
referred to are the following : —
Colotomy 2 Bursae 2
Hernia * . . . .• . . 7 Bone necrosis . . . . 3
Intestinal obstruction i Exostosis i
Exploration of bladder i Hammer toe . . . . i
Extravasation of urine i Amputation of toe . . i
Amputation of hip . . 2 Varicose veins . . . . 4
Hydrocele 3 Disease of ankle joint i
The earliest of these operations was performed on September
gth, 1904, and was for an acute suppuration round the knee
joint, in a girl of 18 ; J gr. cocaine was used and the result was
very good. For the next ten cases the same method was
followed. But it soon became evident that the method had
great disadvantages, viz. grave danger during the anaesthesia
and severe reaction afterwards, and these led to the abandoning
of cocaine for stovaine, which was the agent used in all the rest
of the cases. The cocaine cases were none of them of a serious
character, and two instances will suffice to illustrate the draw-
backs referred to.
J. W., man, aged 47. Radical operation for hydrocele. \ gr.
cocaine. Complete analgesia below navel ; pulse fell to 72, and
Vol. XXV. No. 98. Digitized by GoOglc
306 MR. ERNEST W. HEY GROVES
became very irregular ; the face became, ashy pale ; patient said
he felt desperately iU. Soon revived after J oz. brandy, but had
severe vomiting and headache afterwards.
H. C, man, aged 29. Operation for removing a sequestrum
from the femur. J gr. cocaine. Directly after the operation his
temperature rose to 104" F. with a slight rigor. This was followed
by vomiting and a severe pain in the head and back, which lasted
about twenty-four hours.
These, I believe, agre fairly typical of the troubles which occur
during and after spinal cocainisation. In its toxic effects the, drug,
when used as a spinal anaesthetic, causes a slowing and irregularity
of the pulse which may end fatally. And in its lesser degrees this
phenomenon cannot be very rare, as I experienced it twice in
eleven cases. The severe headache, backache and sharp rise of
temperature with vomiting are quite as or even more severe
than the after effects of a general anaesthetic, and these symptoms
occur very frequently.
But the era of cocaine for spinal anaesthesia is now past, and
its derivatives — stovaine, novococaine and tropacocaine — are on
their trial. And it may, I think, be definitely stated that stovaine,
at any rate, has been proved to avoid the dangers ot cocaine, and
the other drugs are even more highly spoken of, but they do not
enter into the present series.
The first point to be raised is the certainty and completeness
of the anaesthesia. Now this seems to depend chiefly on the
possibility of injecting the fluid into the spinal sub-dural space,
and this in its turn is indicated by obtaining a free flow of cerebro-
spinal fluid Irom the canula before injection. If the fluid can be
obtained freely, then the occurrence of complete analgesia after an
appropriate dose of the stovaine has been injected is certain. In
four of my cases the fluid could not be obtained from the spine,
and in all the anaesthesia was a failure, and in most pubUshed
series there have been at least 3 per cent, of failures from the
same cause. And if this cannot be remedied it constitutes a very
great drawback, inasmuch as one can never be so certain of the
spinal anaesthesia as to be able to dispense with an anaesthetist
in cases of emergency which occur at a distance from help. And
it is therefore worth while to consider the causes of this failure.
Digitized by VjOOQIC
I
ON SPINAL ANAESTHESIA. 3O7
in order to see whether it can be avoided. If the vertebral
column be cut across between the fourth and fifth lumbar
vertebrae, and again between the second and third, the following
appearances are noted inside the vertebral canal. In the former
case the canal consists of a triangle about f in. across and J in.
depth, whose basal angles are very narrow. The dura is, however,
closely attached to the bone. In the latter case the canal is i in.
wide and over ^ in. deep, with much more widely open angles.
But here the dura is hardly attached to the bone at all, and if,
therefore, there is not much tension in the sub-dural space, this
Section of the vertebral canal and -^^^^^'^^ ^^'.T"* l*f ^''"'^^ ''''^
I dura between the second and third ^'^^ vertebra.
! lumbar vertabrce.
space can easily be obhterated by the collapse of its walls. It
is evident from these considerations that two causes may prevent
a puncturing needle from withdrawing spinal fluid. First, the
needle may not get into the vertebral canal at all, which is
especially liable to occur in the lowest space ; and, secondly, the
needle may push the membranes in front of it, and then merely
transfix the two layers of collapsed spinal theca. This is more
likely to be the case in one of the upper lumbar intervals. I
have found that the cases of failure have all been anaemic or old
feeble people, in whom the tension of the spinal fluid is probably
low. And in them also the ventricles of the brain are large, and
the communication with the sub-dural space small, all of which
factors would lessen the Ukeliliood of the spinal fluid escaping
from a puncture.
If these suggestions are correct, the following precautions
must tend to lessen the chances of failure. First thrust the needle
into the space between the fourth and fifth lumbar spines, this
being indicated by the point midway between the highest points
of the iliac crests. The needle should be very sharp apd four
inches long. It must be kept accurately in the mid-line, . and
Digitized by VjOOQIC
308 , MR. ERNEST W. HEY GROVES
follow strictly the sagittal plane. If this fails, it is much better
to try the space between the second and third vertebrae than to
make repeated attempts in the same space. It should if possible,
be done in the sitting or standing position with the head bent
forward. The use of a needle provided with a trocar, and also
with a lateral as well as a terminal opening, is to be recommended
As regards the dose required, in most cases J c.c. of
solution (i mg. of stovaine) is sufficient ; but the susceptibility
of patients varies very much, and this dose will produce a pro-
longed total and extensive analgesia in one patient and only a
short analgesia in another. So that in cases of abdominal disease,
or those in which the operation is likely to last more than one
hour, it is better to use double the above dose.
But, after all, the capacity of the measure to prevent shock is
its chief advantage, and upon this its use in the future will
probably depend. Six of my cases illustrate this point.
T. J., man, aged 52. Old case of traumatic stricture of the
urethra. High grade of retention of urine for ten daj's with signs
of renal sepsis. Extensive extravasation of urine, the parts being
gangrenous and emphysematous. Pulse 140 ; temperature
sub-normal, i c.c. stovaine injection. Multiple incisions and
opening through the stricture into the bladder. General condition
was unchanged during the operation, but he died about three
hours later.
G. S., aged 63. Old inguinal hernia. Became strangulated
nearly a week before adniission to the Cossham Hospital. General
condition bad ; small, irregular pulse ; some vomiting ; abdomen
distended ; right inguinal hernia. At 4 p.m. gave i c.c. stovaine
and operated. Six inches of gangrenous small intestine resected,
but peritonitis evidently already existed, and he died six and a
half hours later. The pulse fell to 108, and he seemed actually
relieved during the operation.
J. K., man, aged 60. Acute spreading emphysematous
gangrene of the right leg. i c.c. stovaine. Amputation through
the hip-joint. Pulse and general condition was better directly
after the operation, but he died three hours after.
A. G., boy, aged 19. Huge sarcoma of the adductor muscles
of the right thigh. J c.c. stovaine. Amputation through the hip
by the anterior racket method The pulse and blood pressure were
noted every ten minutes before, during and after the operation.
Tlie pulse dropped from 140 to 108, and the blood pressiu*e from
Digitized by VjOOQIC
ON SPINAL ANAESTHESIA. 309
115 m.m. to 70 m.m., and then rose to 74 m.m. He was bright,
cheerful and constantly talking to the nurse. He complained
once of feeling faint, but was better after a drink of water. A
few hours after the operation he was bright and cheerful ; his
pulse remained at 108, but was rather small and compressible.
M. G., woman, aged 65. Had had colotomy performed eight
months previously for cancer of the rectum. Intestinal obstrac-
tion had again occurred, and hei abdomen was hugely distended
with visible peristalsis. J c.c. stovaine. Median incision. In-
testines matted together in the pelvis. Paul's tube tied into the
small intestine. Died about twenty-four hours later.
E. A., aged 55. Strangulated right inguinal hernia ; faecal
vomiting, great distension, and very poor general condition, the
obstruction having lasted several days. J c.c. stovaine. A double
loop of gut was strangulated, but not gangrenous ; it was easily
reduced. A very copious fluid motion, amounting to severaJ
pints, occurred on the table at the moment of reduction, and he
became faint and collapsed. The whole operation only lasted
twenty minutes, but he died an hour later.
These six cases represent, of course, the most desperate that
can ever come under the surgeon's care, but for which an attempt
must be made to save life. In four there can be no doubt that
death would either have occurred on the table or without the
return of consciousness. Spinal anaesthesia in such cases is of
the utmost value. It almost entirely abolishes nerve shock,
though of course it cannot prevent the effects of hemorrhage.
It allows the patient full retention of his consciousness, and he
can, at any rate, be safely returned to bed and see and speak
with his relatives. And if it is possible for an operation in such
desperate cases to succeed, it will have a far better chance than
with general anaesthesia. With regard to the last case, I confess
I am in great doubt. Other observers have noted the power of
stovaine to produce intestinal contraction, and it would appear
that in this instance the sudden evacuation of the bowels brought
about the fatal collapse.
Then there are certain cases in which the presence of some
other disease makes a general anaesthetic very dangerous. Such
are particularly, severe lung diseases and diabetes. One example
will illustrate this.
A. M., boy, aged 14. A congenital syphilitic, had double
pneumonia, and an acute periostitis (probably pneumococcal)
Digitized by VjOOQIC
310 DR. F. PERCY ELLIOTT
of the left femur. Under J c.c. stovaine, the femur was cut down
upon, and the bare bone exposed and drained. This had no ill-
effect on his general condition, except that he had some retention
of urine afterwards. He died from the pneumonia a week later.
As regards any ill-effects in the after history following stovaine
anaesthesia, these are very rare. Headache, backache, vomiting
or rise of temperature occur very seldom, and are almost negligible.
In one instance, that of a man aged 52 with caries of the ankle-
joint, an acute bed-sore developed three days later over the
sacrum, and may have been due to some trophic effect of the
spina] analgesia.
In conclusion, I would submit that stovaine-spinal-anaesthesia
presents in ordinary uncomplicated cases no special advantage
over general anaesthesia, and on' the contrary has the draw-
backs of an uncertainty of attainment in about 4 per cent, of
cases, and of not allowing the actual dose to be graduated to
suit the idiosyncrasies of the patient. But it is valuable under the
following conditions in operations on the lower abdomen or legs :—
(i) Operations involving the danger of great shock.
(2) Operations performed in conditions of desperation, where
it is doubtful that the patient will leave the table alive. (3) In
severe diabetes, acetonuria or acid intoxication, severe lung
diseases. (4) In emergency cases, e.g. a compound fracture or
strangulated hernia, where an anaesthetist is unavailable.
THE VALUE OF COMPRESSION
OF THE AORTA IN THE TREATMENT OF
POST-PARTUM HEMORRHAGE.
(Continued.)
BY
F. Percy Elliott, M.B.,
Medical Officer to the Walthamstow Public Dispensary,
Since the publication in the June number of this J our fid,
Vol. XXV., p. 121, of a case illustrating the value of compression
of the aorta in the treatment of post-partum hemorrhage, I have
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ON THE TREATMENT OF POST-PARTUM HEMORRHAGE. 3li
received many communications bearing on difEerent aspects of the
question. The treatment of post-partmn hemorrhage in general
practice, owing to the conditions which prevail, will always be
more oirative than preventative, * and the circimastances at the '
early part of this case illustrate a state of affairs bearing out this
point, and common enough in general practice. The patient was
seen by my assistant when the os admitted the tip of one finger,
and the labour pains feeble and irregular. Bleeding had ceased,
and had not been sufficient to produce any ill-effect on the general
condition of the patient, and an anaesthetic was necessary.
Owing to all these circumstances, delay occurred in immediately
performing version. The manner of delivery did not predispose
to post-partum hemorrhage. After version was performed and
a leg brought through the os, beyond keeping the child on the
lower uterine segment between the pains, no interference took
place until the shoulders appeared, when deUvery was completed
in the usual way. The comparatively rapid deUvery was due to
the onset of strong and frequent labour pains after a leg was
brought through the os, an easily dilatable os, and to the good
down-bearing efforts of the patient. The patient was not kept
deeply under the anaesthetic except during the time that version
was being performed.
The reasons for recording the case were to show that manual
compression of the aorta, despite the assertions to the contrary
made in the recent debate on the subject, (i) is a practical
measure ; (2) that under certain conditions it is the only method
that can be relied on for rescuing the patient from death ;
(3) and that it is not necessarily attended by harm when it is
employed, {a) before delivery of the placenta for arresting
hemorrhage between the second and third stages of labour, or
ib) when it is employed after delivery of the placenta. The case
recorded serves well to illustrate these points.
Compression of the aorta as the primary part of the treatment
of the hemorrhage occurring between the second and third stages
of labour. After a leg was brought through the os, no further
bleeding occurred until the head was deUvered. The hemorrhage
at this stage was obviously due to partial separation of the
Digitized by VjOOQIC
312 DR. F. PERCY ELLIOTT
placenta, an incident usual when the placenta is implanted on
the lower segment of the uterus. The usual proceeding in
serious hemorrhage is straightway to resort to manual separation
and removal of the placenta. The cause of hemorrage, it is
taught, must be removed at once. No rest is given the uterus,
no opportunity afforded for natural separation of the placenta
to take place ; the hand is introduced into the uterus
immediately, the placenta hurriedly removed. Nothing is done
to obviate the necessity for this. Further, while manual
removal of the placenta is being carried out, nothing is done to
arrest hemorrhage ; it is taken for granted that the patient will
be none the worse for the additional loss of blood, and that as
soon as the cause of the hemorrhage is removed the uterine forces
will immediately become adequate, and remain so.
The conditions in this case demonstrate well the advantages of
compression of the aorta as the primary part of the treatment of
hemorrhage occurring in the interval between the second and
third stages of labour.
1. It gave rest to the uterus, a desirable thing in all cases
after the child is born, and especially when severe loss of blood
has occurred. In the case under consideration, although there
were no signs of inertia up to the time of delivery of the head, with
the sharp bleeding which followed immediately, inertia appeared.
2. In addition to affording rest, compression of the aorta
prevented the further exhaustion of the uterus, which would have
occuiTed from the continued loss of blood which is inevitable
until the uterus is emptied.
3. In virtue of this rest and recuperation, opportunity was
given for natural separation of the placenta to take place. Com-
plete separation of the placenta occurred within half an hour after
the birth of the child, as was proved by exploration of the cavity
of the uterus. Moderate pressure on the uterus was all that was
required for the complete extrusion of the placenta.
4. Risk of sepsis was minimised. Owing to hurried removal
of the placenta in the natural desire to remove it as quickly as
possible when hemorrhage has been severe and the Ufe of the
patient is at a low ebb, small pieces of placenta are likely to be left
Digitized by VjOOQIC
ON THE TREATMENT OF POST-PARTUM HEMORRHAGE. 313
adhering to the uterine wall, and to be a source of sepsis
subsequently. Scraping the placental site to remove such pieces
of placenta is also not infrequently rendered necessary by hurried
removal of the placenta. These sources of danger become much
greater when the placenta is morbidly adherent. Although in
this case it was necessary to explore the uterus owing to the
raged condition of the lower portion of the placenta, it is not
always necessary to do so in cases of early partial separation
of the placenta, careful examination of it after delivery alone
being often quite sufficient to obviate the proceeding. Had it
become necessary in this case to remove the placenta ultimately,
with the hemorrhage arrested by compression of the aorta, the
risks consequent on hurried removal would have been avoided.
5. Danger of subsequent hemorrhage from retained pieces of
placenta, the result of hurried removal when bleeding is severe,
was also avoided.
6. The danger to life from the additional hemorrhage
when the placenta is removed manually and without any steps
for the arrest of hemorrhage meanwhile, was also avoided. This
danger is a very real one when the patient has been already
seriously drained of blood, especially when the placenta is
morbidly adherent. There was no obvious feature present in this
case to show that the removal of the placenta could be accom-
plished without great loss of blood, and although bleeding might
not have been great, it would certainly have added greatly to the
peril of the patient. Prompt arrest of hemorrhage was of vital
importance, as, in spite of immediate occlusion of the aorta when
the hemorrhage occurred, the general condition of the patient at
once became very grave.
7. In addition to treating shock by arresting hemorrhage,
compression of the aorta also treated shock far more quickly
and in a much more effectual manner by suppressing the
circulation of blood in the lower extremities. The vital centres
were thus kept better flushed with blood.
In view of all thase facts, I think that compression of the aorta
as the primary part of the treatment of the hemorrhage at this
stage was the best step to take in this case. The result fully
Digitized by VjOOQIC
314 DR. F. PERCY ELLIOTT
justified its employment. At the time when its application took
place the condition of the patient gave cause for great anxiety,
her pulse rising rapidly from 130 to 150 and becoming threadlike,
uterine inertia appearing, and signs of general collapse being
present. After compression of the aorta, witliin three hours, the
pulse had dropped to 120, the uterus had become firmly con-
tracted, no bleeding occurring after releasing compression, and
all signs of collapse had passed off. Compression lasted for about
an hour.
Compression of the aorta as the primary part of the treatment
of the secondary post-partum hemorrhage. The hemorrhage in this
case occurred suddenly, after a period of over eight hours' freedom
from bleeding. I regret that I omitted in my former paper to
mention the circumstances which attended and appeared to
determine the onset of secondary post-partum hemorrhage in this
case. It was stated that the patient was of an excitable nature, ^
and it was following an outburst of mental and physical excite-
ment that the hemorrhage occurred. The uterus, it will be
remembered, had been previously thoroughly explored ; no
placental remains were present, and the organ had been com-
pletely emptied, and good contraction and retraction secured.
There was, therefore, no question of retained portions of placenta
or chorion. As secondary post-partum hemorrhage is not un-
commonly associated with mental and physical excitement, it is
reasonable to assume that in this case the hemorrhage was due to
separation of thrombi in the uterine sinuses, induced directly by
such a cause. When the patient was seen shortly after the
occurrence of the hemorrhage, she had already passed rapidly
from faintness, restlessness, and air hunger to cyanosis, convulsion,
unconsciousness, and loss of wrist-pulse ; respiration had ceased,
and the patient was apparently dead. She was lying in a pool of
blood, and the uterus extended into the epigastrium, and was full
of blood-clots. Massage at this time failed to evoke the slightest
response. The uterus was immediately forcibly squeezed and
emptied, and pressure then applied through the flaccid and
attenuated organ on to the aorta, the feeble pulsation of which
showed that life was not yet extinct. With the patient in this
Digitized by VjOOQIC
ON THE TREATMENT OF POST-PARTUM HEMORRHAGE. 315
moribund condition, any method of stimulating the uterus would
have been utterly futile. Animation had first of all to be restored,
and only prompt arrest of all bleeding and prompt and powerful
treatment of shock and collapse coiuld accomplish this. Hemorrage
could not have been arrested by endeavouring to rouse the uterine
forces. Contraction and retraction, the securing of which we look
on as the final end to be obtained for the permanent arrest of
hemorrhage, were completely absent. ^These forces had first to
be restored before thej^ could take part in the arrest of the hemorr-
hage, and their restoration had to be complete if they were to be
relied on for permanently arresting the hemorrhage. For the
restoration of these forces, it was first of all necessary for all
bleeding to cease. Clotting of the blood in the uterine vessels is
the only means of arresting hemorrhage when contraction and
retraction are absent. It was necessary to arrest bleeding
immediately. The methods of inducing clotting, as advocated
in text-books, aim at applying pressure to the bleeding part. The
use of perchloride of iron injection is regarded as dangerous and
uncertain, and is obsolete. Pressure on the placenta site by
plugging the utero-vaginal canal would have been useless here, as
its success depends on a certain amount of remaining energy in
the uterus ; and, again, it could not have been carried out com-
pletely before the patient died. Injection of hot water would
also have been useless. Compression of the uterus is the method
recommended for arresting hemorrhage when the uterine forces
are rx)mpletely exhausted. What were the chances of success of
this method in this case at the time when compression of the aorta
was adopted ? There were several features present which
rendered compression of the uterus an uncertain method for
rescuing the patient.
1. Prompt arrest of hemorrhage was imperative. To have
introduced the unsterilised hand into the vagina and apply
pre.ssure to the uterus, even although the hand was not
introduced into the uterus, would have been to incur great
risk of sepsis. The patient certainly must have died long
ibefore the aseptic ritual was complete.
2. The bleeding area was situated on the lower portion of the
Digitized by VjOOQ IC
3l6 DR. F. PERCY ELLIOTT
lower uterine segment. Compression of the body of the uterus
would not have ensured perfect pressure over the whole of the
bleeding area for this reason, and for another which will be
mentioned later. Compression of the uterus by pushing the cervix
forward with one hand and anteflexing the body with the other,
rarely finally arrests hemorrhage, and, as will be shewn, did not
admit of satisfactory application in this case. Compression with
one hand inside the uterus on the placenta site and the other on
the abdominal wall, is a very uncertain way of arresting hemorr-
hage when the uterine forces are entirely absent. The risk of
sepsis being much greater than with any other method of com-
pression, and owing to other circumstances present in this case,,
it could not be employed for arresting hemorrhage even tem-
porarily.
3. The uterus extended into the epigastrium. It would have
been perfectly impossible to compress such an unwieldy organ
satisfactorily.
4. Notwithstanding prompt arrest of hemorrhage, contrac-
tion of the uterus did not reappear until after an hour's com-
pression of the aorta, and it was not until some considerable time
after this that contraction remained satisfactory. Owing to the
desperate condition of the patient during the greater part of five
hours, it was necessary to prevent any further loss of blood during
this period. Compression of the uterus by any method cannot be
kept up continuously for any length of time, and there is no
certainty that loss of blood will not occur during the intervals of
changing compressors.
5. Shock and collapse were extreme, and demanded prompt
and powerful measures of treatment. Compression of the uterus
alone would not have treated shock and collapse promptly and
effectually enough in this case, and the life of the patient was at
too low an ebb to have responded to such auxiliary measures as
hypodermic administrations of strychnine, ether, &c.
Compression of the aorta was the only method that offered any
chances of success in the treatment of the secondary post-partum
hemorrhage in this case. The advantages of the method were well>
shown in this case. It could be applied immediately ; its satis-
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ON THE TREATMENT OF POST-PARTUM HEMORRHAGE. 317
iactory application was quite unaffected by the position of the
placental site, or by the dimensions of the uterus ; it could remain
continuously in action for many hours, pressure being main-
tained longer by one individual than can be in compression of the
uterus, and the changing of compressors not being accompanied
by loss of blood ; it treated shock promptly and much more
powerfully than compression of the uterus would have done.
Twelve hours after the moribund condition of the patient, the
pulse had dropped to lOO, and was strong and fairly full, all signs
of collapse had disappeared, the uterus was firmly contracted,
and no bleeding whatever had occurred since its arrest at the
beginning of this period. Death occurred from heart-failure due
directly to sudden and violent exertion about fourteen hours after
the cessation of bleeding. At the time of its occurrence no further
bleeding took place, the uterus being firmly contracted, and
remaining so.
The fact also that posture, bandaging of the extremities, and
saline transfusion formed a part of the treatment of the case does
not affect the chief points at issue. Although these measures
were employed, and were of unquestionable value, compression
of the aorta formed the most important part of the treatment ;
without it nothing would have been accomplished. It might be
argued that it would have been a better plan to douche out the
uterus with hot water while the hemorrhage was arrested by com-
pressing the aorta. The effect of hot water on severe hemorrhage
cannot always be relied on, and in this case it would have been
unwise to employ a measure which is not always certain.
The objections to compression of the aorta. The chief objec-
tion urged against its use is its alleged detrimental interference
with the functions of the uterus by curtailing its blood supply; 1
Although the blood-supply of the uterus by the uterine arteries
is prohibited when the aorta is occluded, on anatomical grounds,
quite enough blood should reach the organ bj?^ the ovarian arteries
to enable it to contract and retract to the extent jiecessary at least
for the separation of the. placenta, and for the complete arrest of
hemorrhage. The portions of the uterus chiefly affected when
1 Fitzgerald, Practitioner, 1906, Ixxvii. 652.
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3l8 DR. F. PERCY ELLIOTT
occlusion of the aorta takes place are the cervix, the lower uterine
segment, and the lower portion of the upper uterine segment.
The fundus receives a large part of its blood-supply from the
ovarian arteries i. Free anastomosis exists between the branches
of the ovarian and uterine arteries, especially in the upper uterine
segment. When occlusion of the aorta takes place, the supply of
blood is greatest in that portion of the uterus in which muscularity
is greatest. From an anatomical point of view, therefore, a fair
amount of blood should find its way to that part of the uterus which
is most concerned in contraction and retraction. The question is
whether actually a sufficient amount of blood is supplied to the
uterus when the aorta is occluded to allow of the contraction and
retraction necessary for the expulsion and separation of the
placenta, and for the arrest of hemorrhage. This case supplies
abundant clinical evidence on the last two points. When com-
pression of the aorta took place before delivery of the placenta,
during its application the uterus was observed to contract. At the
end of half an hour the placenta still remained undelivered. The
uterus was then grasped with one hand and pressure applied on the
fundus, and in the direction of the sacrum. This proceeding
resulted in immediately effecting complete extrusion of the
placenta. The pressure exerted was not unusually forcible, being
about the same as is required when the placenta has separated
and is merely lying in the lower uterine segment. The question
of the placenta not having separated did not suggest itself, owing
to the ease with which it was expressed. The reason for intro-
ducing the hand into the uterus after deUvery of the placenta was
because the lower portion of the placenta — the early detached
portion — ^was in such a ragged condition. As has been mentioned,
there were no placental remains found when the uterus was
explored, and this fact supports the conclusion that complete
separation had occurred when expression took place. That the
application of compression of the aorta before delivery of the
placenta, and in the treatment of the secondary post-partum
hemorrhage, did not interfere with the contraction and retraction
necessary for arresting hemorrhage, is clearly proved by the record
1 Jellet, Manual of Midwifery, 1905, p. 47.
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ON THE TREATBfENT OF POST-PARTUM HEMORRHAGE. 319
of events. When compression was used before delivery of the
placenta, no hemorrhage followed the release of compression,
and an interval of eight hours' freedom from hemorrhage
ensued, and the cause of the hemorrhage at the end of this-
period was quite unconnected with compression of the aorta.
When compression was employed in the treatment of the
secondary post-partum hemorrhage, contraction and retraction
were completely absent. After an hour's compression, and during
its application, the uterus hardened, became smaller, and massage,
which previous to compression of the aorta failed to produce any
effect, soon succeeded in bringing about firm contraction. No
bleeding followed the release of compression. Further, the con-
traction and retraction resulting remained perfectly adequate up
to the time of the patient's death, from heart-failure, eight hours
after the discontinuance of compression. These forces indeed must
have been unusually adequate, for in spite of the patient jiunping
out of bed, the loss of less than a tablespoonful of blood followed the
incident. Even after death the uterus was still firmly contracted.
I think, therefore, that conclusive evidence was furnished that
compression of the aorta did not affect injuriously the contractile
and retractile functions of the uterus in their power for accom-
plishing separation of the placenta, and for arresting hemorrhage^
either when its apphcation took place before or after delivery of
the placenta. The evidence derived from this case on these
points is very valuable. The fact that the placenta separated
naturally, and that contraction and retraction, which were
previously completely absent, reappeared, and in spite of five
hours' occlusion of the aorta, remained permanently adequate, is
sufficient proof that compression of the aorta I think did not
interfere with the power of the uterus for affecting separation
of the placenta and for arresting hemorrhage.
The irksomeness of the method is another objection that has
been brought against compression of the aorta. The main-
tenance of adequate pressure is not as irksome as would appear
to those who have not employed compression of the aorta. It is
certainly very much easier to keep up effectual pressure on the
aorta than it is to compress the uterus bi-manually for even a short
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320 THE TREATMENT OF POST-PARTUM HEMORRHAGE.
tune. Although it was necessary in this case to keep up pressure
for five hoius, the circumstances were exceptional, one hour's
compression being an outside limit in most cases, according to
those who have used the method frequently, i An intelligent
nurse can easily apply pressure, and as it is easy to prevent loss
of blood when changing compressors — the new-comer placing the
fist above or below that of the compressor before the latter releases
pressure — ^no disadvantage attaches to changing compressors as
often as may be necessary. The danger of reactionary hemor-
rhage and of syncope follorwing the discontinuance of compression
are avoided by withdrawing pressure gradually. With regard to
the other objections brought forward, these are not of great im-
portance, being easily overcome if compression is properly
employed. These objections and the means of overcoming them
were mentioned in my former paper.
In conclusion, I may say that I have used compression of the
aorta on another occasion since in consultation, and this further
experience has served to strengthen the conclusions arrived at in
this case. The method as the primary part of the treatment of
hemorrhage between the second and third stages of labour, due to
partial separation of the placenta, possesses great advantages over
immediate manual separation of the placenta, in those cases
where serious exhaustion has been produced from tedious labour
or loss of blood. If, after waiting half an hour, the placenta is not
expelled naturally no harm is done, hemorrage being arrested;
on the contrary, rest is given the tired uterus. Pressure on the
uterus can then be tried, and if this fails to expel the placenta, or
if the expressed placenta is incomplete, the uterus can then be
emptied by introducing the hand, compression of the aorta con-
tinuing until the organ is completely emptied, and contraction
_and retraction complete.
1 Stanmore Bishop, Practitioner, 1906, Jxxvii.
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A CASE OF GENERALISED SARCOMA, WITH BLOOD
CHANGES.
BY
F. G. BUSHNELL, M.D.,
Pathologist, Stephen Ralli Memorial, Brighton.
Jessie, aet. 21, under the care of Dr. Maynard. Patient was
admitted on 24th September, 1906, for severe epistaxis and
a hemorrhagic and purpuric eruption. There was a history of
epistaxis occasionally for years. She was taken ill suddenly three
weeks previous to admission with sickness and vomiting. On
admission, there was considerable anaemia. There were enlarged,
softish glands in the neck and axillae. The splenic dulness ex-
tended to the costal margin, and the liver dulness from fourth
rib to one finger's breadth below border of ribs. There was a hard,
slightly movable, tender, nodular mass of tumour in the pelvis
to each side of middle line, with a general tenseness of abdomen.
The breasts were very tense, hard and nodular, and were said to
have been so for three weeks. There were hemorrhagic purpuric
spots on the arms and legs.
The temperature was 101.6° on admission. It rose on 26th
September, 1906, to 106.2°, with a severe rigor. The patient died
on the 27th September, 1906, at 2 a.m.
Post-mortem findings (by Dr. Nockald). — Malignant new
growth of ovaries, retroperitoneal glands, mesentery, omentum,
portal fissure, liver and breasts, peritoneal effusion, subcutaneous
and petechial hemorrhages.
The thoracic viscera were not examined, permission being
refused. For this reason also a limited examination of the
bone-marrow could only be made.
The subject was a well nourished girl. There were numerous sub-
cutaneous hemorrhages, especially on the outer side of the left leg,
and on the inner side of the right leg. There was also a petechial
eruption, most marked on the legs. On opening the abdomen, a
moderate quantity of dark yellow fluid was found in the peritoneal
cavity. The great omentum was matted together, and contained
masses of what appeared to be new growth. These were diffuse,
and on section had a pearly lustre and showed hemorrhages. The
mesentery had undergone a similar change, which was generally
most marked near the intestine. The iliac glands on the left side
were not distinguishable as such, but their site was occupied by
Vol. XXV. No. 98.
'-^2 Digitized by Google
322 DR. F. G. BUSHNELL
a large mass of growth simflar to that in the omentum and mesen-
tery, which reached from the fourth lumbar vertebra along the
brim of the pelvis almost to the pubic bones.
The right ovary was large and nodulated, firm in consistence,
and showed a blood C5^t about two cm. diameter on the surface^
It was not adherent to any of the surrounding structures. On
section, the mass was solid, tough, and showed hemorrhages, and
had all the appearance of a sarcoma. There were no naked-eye
evidences of ovarian tissue. The left ovary was similar in
appearance to the right, but only about half the size.
There were small masses of growth beneath the peritoneal
covering of the uterus, particularly on the posterior surface. The
cavity of the uterus was somewhat larger than normal. The
vagina was normal, also the kidneys and supra-renal capsules.
The liver was rather pale ; the hilum contained masses of new
growth. The gall-bladder was very thickened, apparently by
inflammatory change (microscopically, this was seen to be sarco-
matous). The spleen was slightly enlarged, but externally and
on section was normal.
The breasts were firm, and contained numerous nodular, rather
hard masses, which resembled new growth on section, and were
hemorrhagic. Glandular breast tissue was seen between the
nodules.
Microscopic examination. — ^The blood, ovaries, lymph glands,
mesentery, oviduct, uterus, liver, gall-bladder, marrow and breasts
were examined microscopically by ordinary (haematoxylin and
eosin, Van Giesen) stains, by Pappenheim's p5n"onin methyl green,,
by Leishman's blood stain, and by eosin methylene blue stain in
order to study the nature of the neoplasm and its relationship,
if any, to inflammatory tissue, or to the lymphocytes of the blood.
Micro-organisms, too, were searched for by Gram -Weigert's
method of staining, but cultures of the blood were inadvertently
not made before or after death.
The ovaries show polyhedral or rounded cells, with large nuclei
and small amount of cytoplasm ; rarely they are swollen and
dropsical. The latter usually is acidophilous. Between the cells
are delicate fibrils ; in places the arrangement is alveolar. There
are areas of degeneration and hemorrhages. In places there is
a loose connective tissue with round or spindle cells, and red-
blood cells are present. There are many thin-walled blood
vessels.
The breast. — The fat or fibrous tissue is diffusely, and in places
densely, infiltrated with large rounded cells resembling those in
ovaries and is vascular, very necrotic and hemorrhagic.
The liver. — ^The portal'fissure is the seat of a round-cell growth,,
which diffusely penetrates the liver and its capillaries ; the peri-
portal tissue is infiltrated far away from the fissure.
The mesentery and omentum show growths of polygonal cells
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ON A CASE OF GENERALISED SARCOMA. 323
infiltrating the fat. The cells have large nuclei, with granules of
chromatin and a thin rim of protoplasm.
The walls of the gall-bladder and the folds of its mucosa are
infiltrated densely with round cells.
The oviduct (left near ampulla) has undergone sarcomatous
change ; also the ihac glands.
Tliere is sarcomatous tissue between the uterus and bladder,
and diffusely throughout the pelvic viscera. The rib marrow
was fatty.
Some of the cells are large, with two or more nuclei, but
there are no large giant cells. As a rule, the cells are larger than
mature lymphocytes.
No leucoc5rtes or plasma cells appear.
The patient died three days after admission, and the day before
death had 50 per cent, haemoglobin, 2,960,000 red cells and 13,400
white cells, with a colour index of 0.83, and i white to 222 red
cells. There was a marked relative lymphocytosis.
Blood examination. — Haemoglobin, 50 per cent.; reds, 2,960,000 ;
whites, 13,400 ; colour index, 0.83 ; white to red, i to 222. Poly-
nucleaxs, 13.0 ; large lymphocytes, 37.3 ; small l5miphocytes, 29.1 ;
transitionads, 12.6 ; eosinophil polynuclears, i ; myelocytes, 3.4 ;
large hyaline, 2.1.
This case is one of great interest, as it illustrates the close
association of sarcomata and blood diseases. I have seen l5mipho-
cythaemia with deposits in the Uver, kidney and marrow, and not
markedly affecting the l5miph glands ; and again lymphocythaemia
has been found with malignant mediastinal growths. Lymphade-
noma has recently been described showing malignant (sarco-
matous) infiltration of adjacent structures, and l5miphosarcoma
and sarcoma are found to occur with or without relative white
cell changes in the blood. Daniels says that sarcomata always
possess a stroma ; otherwise l5miphosarcoma is characterised by
continuous infiltration, suggesting a direct infection by lymph
paths, whereas sarcoma is said to form metastases more frequently.
(The distinction of lymphosarcoma from Hodgkin's disease by the
infiltration of the lung in the former can no longer be maintained.)
I would place our case among the sarcomata, though I admit
that the various deposits were not proved to be truly ** metas-
tatic" beyond doubt. It is characterised by the marked
"relative lymphocytosis" of the blood of the large cell type,
by its hemorrhagic eruption, and its diffuse growth (as seen in
the mesentery, omentum and portal fissure of liver). It is thus
Digitized by V^OOQIC
324 DR. F. G. BUSHNELL
illustrative of the sarcomata which are at one end of the scale,
of which lymphocythaemia is at the other. This supports
the view taken by Banti that both myeloid and lymphsitic
leukaemias are true tumour developments, a sarcomatosis
of medullary and lymphatic elements respectively. Banti
believes a lymphoc5^osis may be mistaken for a discharge
of sarcoma cells. It is suggested by Salaman that the clinical
differences in these cases are physiological, and depend on the
stage of development of the lymph-cell forming the tumours, in
some cases resembling the finished lymphocyte ; in others, and
more malignant ones (as this of ours), resembling the lympho-
gonia of the germinal centres.
The sarcomatous nature of infective venereal tumours in
dogs was described at the last meeting of the Pathological
Society of Great Britain and Ireland, and has been con-
firmed by Seligmann. (They are similar to those described
by Bellingham- Smith and Washbourne.) They are not the
result of direct extension only, but may show true metastasis
(e.g, into the testis). These tumours are then, as Hoch says,
contagious malignant neoplasms, usually locally malignant.
Our case showed no disease of vulva or vagina, and there is no
evidence to place it in this category.
The connection between the sarcomatosis and the cutaneous
hemorrhages is unknown. Engel Martens and Douglas obtained
experimentally no specific precipitation of blood to cancer. Von
Dungem, Beebe and Pearce, in the Journal of Experimental
Medicine (vol. 7), have shown that haemolytic and haemagglu-
tinative properties exist in a serum obtained by injection of
various crushed tissues, mixed with blood, into an animal. It
is possible such anti-bodies were circulating in this patient's
blood ; and if so, their presence was dependent on an affection
of the blood itself.
Whether the blood was altered in its alkali content is not
known. Neither did I find evidence of the phenomena observed
by Farmer, Wallien, and Moore in the leucocytes in the active
zone around early cancers. These indicated an interchange
between the chromosomes of the daughter nuclei of the leucocytes
Digitized by VjOOQIC
ON A CASE OF GENERALISED SARCOMA. 325
and tissue cells after mitosis. No evidence of an infectious
nature, or of " evolutionary " changes in the tissues, was observed.
That Nature has some function for this apparently purposeless
proliferation is certain.
A word may be said as to nomenclature of this disease.
Warthin suggests " leucoblastomata " — based on Powell White's
classification apparently — and " malignant lymphomata " or
"multiple sarcomata," and " sarcomatosis " are suggested
(among others) by some authorities.
In respect to the relation of lymphosarcoma to Hodgkin's
disease. Gibbons records nine cases of Hodgkin's disease, with five
autopsies, in which the blood picture Was normal, and there were no
relative changes in leucocytes. The glands showed the prolifera-
tion of the germ centres of follicles and endothelium of sinuses, and
presence of giant cells, eosinophils, and a few plasma or poly-
morphonuclear cells, with changes in connective tissue structure,
as described by Reed and Longcope, Simmons, and others. In
the hard variety peculiar giant cells and small lymphoc5rtes are
striking features. The capsules showed infiltration, and even
penetration (and incidentally the capsules were seen to be
secondary envelopes). The muscle cells may be invaded, destroy-
ing them, or the submaxillary gland be invaded. The metastases
present certain features of lymph glands ; the boundaries usually
are sharply defined, but without a capsule, and may infiltrate
and destroy tissues around. In the spleen they may appear in
Malpighian bodies, and stretch out as ill-defined nodules into the
pulp.
The metastases in the lungs showed that they were not alone
developments of pre-existing lymphoid "tissue in organ, but
malignant metastases pushing into adjacent tissue and destro5dng
it. They occurred, too, in the lower lobe, and away from a
bronchus.
The five autopsies of nine cases showed involvement of lymph
glands all over the body, with metastases in liver in four, in spleen
in four, in kidney in two, in lungs, pericardium and pancreas in
one each. Of other four not coming to post mortem, one showed
involvement of all the external glands.
Digitized by VjOOQIC
326 DR. WILLIAM COTTON
In lymphadenoma Andrewes describes a loss of all germ
centres, diminution of lymphocytes, increase of reticulum, and
the presence of eosinophil cells and giant cells. Thus lympho-
cytes, lymphoid tissue, and connective tissue may be affected
by a proliferation which can only be described as malignant;
and l5anphocytes, plasma cells and fibroblasts have been
observed to be stages of growth by which wandering blood cells
become fixed tissue cells.
PROPORTIONAL REPRESENTATION AND THE
COMPARISON OF RADIOGRAPHS.
BY
William Cotton, M.A., M.D., D.P.H.,
Member of the Council of the Rontgen Society,
Not only does the radiograph of any part of the body need
interpretation singly, but it may as regards the outlines depicted
require to be compared with any other of the same part in others
as one of a series of cases. In the attempts made up to now to
adapt the radiographic art to clinical uses, one essential principle
at least seems to have been almost entirely ignored, namely that
(for reliable comparison of radiographs of corresponding parts) the
distance of the focus tube from the parts to be represented
should be proportioned to the size of these parts. In other
words, corresponding parts of objects differing in size must be
radiographed under equal angles if the resulting radiographs
are to be at all comparable one with another.
The possibility at £ill of clinical radiography rests on the
underlying assimiption — till it is disproved — that in persons who
are about the*same age, and who are of the same sex, and of the
same degree of fatness and leanness, but who differ in size, the
corresponding regions of the body are in the geometrical sense
similar to one another in their dimensions — that is, are enlarged
or diminished models of each other — except in so far as their
proportions may be altered by the effects of disease or of
Digitized by VjOOQIC
ON RADIOGRAPHS. 327
injury, or it may be by movement. This assumption is
probably rarely quite true over the whole body, as where, for
example, the man 5 feet 8 inches in height takes " tens " in
boots, while his friend, who measures 5 feet 10 inches, gets
along comfortably with '* eight and a half." Yet so far as the
feet are concerned, the bony skeletons of the larger feet are
probably more likely to be similar to those of the smaller, each
to each, than the containing pairs of boots, though these might
very well be so too. One cuboid bone is to be regarded anatomi-
cally as similar to another. The assiunption is probably
approximately true in reference to the bones and bony distances
of such segments of the axial and appendicular skeleton, and to
such organs as the liver and heart, as are likely to come within
the purview of the radiographer. According to this assmnption,
if we take two normal frozen bodies of the same age, sex and
build, but differing in size, and if we make sections through them
in various directions, we would expect on the surfaces of any pair
of sections made in the same direction to be able to draw any
number of triangles we please by a network of intersecting hues
drawn between points corresponding anatomically, and we
would expect to find by measurement that each triangle in the
larger or smaller section would be similar respectively to the
corresponding triangle in the smaller or larger section in every
parallel pair of sections cut. Any dissimilarity observed would
be the mark of abnormality.
But if this fundamental assumption be proved untrue, then
there is an end at once to any exact use of radiography by the
clinical surgeon or by the clinical physician. Nevertheless, for
the purposes of the present argvmient, it is held to be prima facie
true, and my present contention is that for proper comparison
of radiographs similar parts in subjects of different size must
be X-rayed under equal angles, that is at a distance of the focus
tube from the parts proportional to the size of the parts.
In X-raying a part of the body for diagnosis, we virtually
run a sheaf of sections simultaneously through the part of the
body under examination, these sections being inniunerable and
radiating through a common Axis (the radiographic Axis),
Digitized by VjOOQIC
328 DR. WILLIAM COTTON
namely the particular ray that passes through the centre of
the object we wish to take. At the same moment we project
a sort of linear image of some of the contents of each intervening
section upon the intersecting plane of delineation (plate or screen)
by means of such of the rays emanating from the anticathodal
point of emission (the radiographic Centre) as may survive the
obstacles in their path. In radiographing for comparison the
same region in a small man and a large one of the same age and
build, if the Axis passes through corresponding anatomical points
and the Centre is similarly situated to the parts, then the two
resulting radiographs will be similar the one to the other on aU
parallel planes of delineation ; and if the distance of the plane
of delineation from the Centre of the focus tube in the one case
is equal to the distance of the "plane of delineation from the Centre
of the focus tube in the other, then the resulting radiographs
(barring morbid changes of size and shape) will not only be
similar but equal in every respect, as might be proved by actual
superposition. In geometrical parlance, the projections of
similar solids on parallel planes by points similarly situated are
similar, and may be equal.
In illustration of the foregoing remarks, I have tried in the
accompanying diagram to show, as simply as possible, by means
of four very conventional figures, what one might expect to
find radiographically in the case of corresponding sections of
three individuals, one of whom is larger than the other two,
these two being equal in size externally. The larger circles
represent sections of the thorax made transversely to the long
Axis of the body, about the level of the fourth costal cartilage
in front and the ninth dorsal vertebra behind, viewed from
above. The smaller enclosed shaded circles represent the re-
spective hearts. O is in each case the anticathodal Centre of
emission, and O N is the radiographic Axis, drawn in each case
through the right border of the sternum in front, and a point
on the right side of the body of the ninth dorsal vertebra, pro-
portionally distant from the mesial plane of the body. This
Axis touches the right border of the heart, known to be similarly
situated in I., II. and III. * ^ is the extreme limit to the right
Digitized by VjOOQIC
ON RADIOGRAPHS. 329
Digitized by VjOOQIC
330 DR. WILLIAM COTTON
at the level chosen of the thoracic cage, namely an angular-
portion of the shaft of the fifth rib. The line R R represents
the radiographic plane of delineation ; the shorter transverse
line P P parallel to the last, a plane of photographic enlargement
of the radiographs in III. and IV., producing as it were (by
appropriate use of the enlarging camera) the primary image in
the X-ray plate to the same scale as the radiographs in I. ancfll. ;
O N (that is the distance of Centre from P P) in III. and IV.
being made equal to O N in I. and II. (that is the distance of
Centre from R R). The black represents in each case the shadow
or projection H N and h n of the opaque hearts ; and N F and
n f the projection of ^ and of all the intervening space between
O N or O n and O F or O f . In all these cases the radiographic
plate or screen is supposed to be as close to the posterior wall of
the thorax as possible, i.e. in contact with the body according to
the prevailing practice to secure greatest degree of clearness of
image — and the Axis to be at right angles (what is called normal)
to R R, so that when the radiographs were taken the distances
between O and the remotest part of the body from O along the
Axis and the distance of O from the plate coincided. It need
not, however, have been so ; theoretically for comparability of
results the essential distance is the distance of O from the body at
N (I. and II.) and n (III. and IV.) ; and the essential in regard
to the plates is that they should be parallel to each other.
Nevertheless it is of the highest practical convenience that the
plates should be at right angles to the Axis at N, and as near
N as possible. The distance of the parallel plates or screens
from O is not essential as a matter of geometry, though it is of
great importance for shortness of exposure that this distance
should be as small as possible ; but we do find that when the
distance of the plate from O in one case is equal to what it is in
another, then the two plates arc on the same scale, and can be
compared by superposition, provided always that the axial
distance of the object from O in the one case is to that of the
other similarly proportioned to the respective size of the objects.
In I. and IV. the hearts are equal in size ; II. and III. are
representations of the same individual.
Digitized by VjOOQIC
ON RADIOGRAPHS. 331
In I. the axial distance of O from the remotest part of the
l>ddy has been purposely made equal to twice the distance of
^, from the tip of the spine of the eighth dorsal vertebra. It
might, of course (subject to technical difficulties) have been
made any other multiple of any other distance between bony
landmarks ; in practice (so long as we stick to the same multiple
or sub-multiple of corresponding distances) no doubt in future
it will be found convenient to take the distance between and
the nearest point of the body along the Axis, and make it pro-
portional to the thickness of the body perpendicular to the plate.
In II. the axial distance of O from the remote part of the body
is the same length as in I. ; but in'III. and IV. the axial distance
•of O from the remote part of these bodies is a length the same
multiple* of the distance of ^ from the eighth dorsal spine of
these bodies, as O N is of the corresponding distance of ^ there
in IV. from the eighth dorsal spine of that body, namely 2.
These elements will be found tabulated in the annexed
paradigm. The unit of measurement employed would amount
to about a quarter of an inch in an actual radiograph of the
chest.
Now it is evident that from the actual radiographs I., II.,
III. and IV., different radiographic experts would come to'
different conclusions with more or less reason on their side.
For instance, one radiographer would carefully measure H N
and h n ; he wpuld make out the heart in III. to be somewhat
and the hearts in I. and IV. greatly enlarged, taking no doubt
the heart in II. as the normal, and acting on that curious principle
in the morbid anatomy of the heart, whereby hearts always
appear to be larger and never smaller than each other. But II.
and III. are the same person ; therefore the same object is at
the same time larger and smaller, which is absurd. Another
expert more philosophically would go by the ratios of H N or
h n to N F or n f, N F and n f being the projections of ascer-
tainable parts. He would probably make II. the standard, and
regard the hearts of I. and III. as *' equally enlarged " and of
IV. as greatly so. On its being pointed out to him that II. and
III. were from the same original, he would at once ask for the
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332
DR. WILLIAM COTTON
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ON RADIOGRAPHS. 333
distance of O from the plate in each case ; and on learning that
N and O N in I. and II. were equal, and that O n and O n in
III. and IV. were eqiial to* each other, but shorter than O N in
the other pair, he would put I. and II. apart from III. and IV.
as belonging to two series not comparable with each other, and
proceed to X-ray IV. anew, making the distance of O from n
therein equal to what it was in I. and II.
How, then, are these discrepancies to be reconciled ? To
avoid a task for which I feel personally unfitted of a rigid mathe-
matical demonstration, I now venture under the form of an
apologue to introduce a semi-mythical personage, whose methods
of procedure are not unfamiliar to the readers of this Journal,
In a certain far country, lying towards the Great River, even
the River Euphrates, there lived two learned hikim or physicians.
The one of them belonged to the sect of the millimetrists, the
other relied on what he called common sense. Both had
graduated and postgraduated with credit at a northern university
of the Giaoiu", and had returned to practice the arts of medicine
among their confiding kinsfolk at home. These two had met
for the purpose of comparing some radiographs they had taken
in the case of two or three of their patients. The patients com-
plained of symptoms compatible either with indigestion or heart
disease. The radiographs resembled the hypothetical cases of
my text, and the two learned physicians came almost to blows
over the very discordant indications thereon. At last, staggered
by the discovery that II. and III. were from a patient whom they
were both attending to at the same time, unknown to each other,
they at length agreed to lay their differences before a certain
wise man named Zadig, who had a great local reputation for
setting down disputants and putting a full stop to people's
troubles, and, in short, for seeing farther into a haystack
than most. The last, having heard what they had to say with
true oriental politeness, and having elicited from them some
such 'particulars as these I have tabulated, retired into a small
obscure chamber in the interior of his dwelling. There, having
lighted a Uttle taper of wax (which he kept near his bedside
during the hours of darkness in case of being aroused by the
Digitized by VjOOQIC
334 ^R- WILLIAM COTTON
robbers who infested that neighbourhood), he proceeded to
throw on the white walls of his dark room the shadows of a
sheep's heart and of some ribs of mutton (carefully denuded of
flesh), which Jie happened to have by him. In doing so he
watched attentively th^ various grazing contours made by his
little cone of light upon the objects in his hand, as he passed his
taper to and fro and back and forth. Having again emerged to
the light of day, he sat awhile meditating, and drew on the sand
with a twig some such diagrams like to those on page 329. Then
slightly closing one eye, he thus addressed his expectant listeners
in the sententious manner affected by eastern pundits : —
*' Brothers, peace be with you. It is vain to fight about
shadows. Life is short, art is long, and a straight line is the
shortest. Truth lies on both sides. Clearly, my brethren, in
IL the triangle O H N is not comparable with the triangles
O H N and O h n in I., III. or IV., nor the triangle O N F there
with O N F and O n f in the others, the two angles at O in II.
being respectively unequal to the corresponding angles at in
the other three figures. Hence in II. the ratio of HN to NF
cannot be compared to the ratio of H N .to N F or of H n to n f in
I., III. or IV., or in any other figures taken with the same pro-
portional distance of O from the object, as in I., III. or IV. So,,
friends, you had best lay aside the radiograph II. ; it is but a
single term of another series ; for I do now perceive, that the
heart being unto X-rays a smooth and globular organ, unless
it be radiographed under the same angle at O in all cases, it is the
shadow of a different profile that will be cast in each case. Where-
unto let the stereoscopists take heed.
" But in I. and III. the triangles O H N and O h n are both
similar to each other, and likewise the triangles O N F and
o n f ; so that H N : N F : : h n : n f . So I conclude that the
hearts in these two men are not disproportionately enlarged as
compared with the rest of their chests ; and I prognosticate that
they will do well whenever you do cease to treat them. Praise be
to Allah ! hearts are trumps, not spades. Further, I do reckon
that the size of the heart in the one is to the size of the heart in
the other directly as the size of the thorax in each.
Digitized by VjOOQIC
ON RADIOGRAPHS. 335,
" But in regard to the original of IV., I perceive he is in a
very bad way, for I doubt not his heart is either much larger
than it ought to be, or else it protrudeth out through the front
of his bosom. If he live long enough, he will surely die. For
though the triangles O H N and O h n in IV. are dissimilar to
H N and O h n in I. and III., yet verily the triangles O N F and
n f in I., III. and IV. are to each other similar, and the ratio of
H N to N F and of h n to n f in IV. is much greater than the
ratio of H N to N F and of h n to n f in I. and III. Nevertheless,
1 cannot tell you how much larger the heart of IV. is than the
hearts of I. and III., unless you can assure me that the right
border of the heart in IV. is similarly situated to that of the
right border of the heart in I. and III."
So they prostrated themselves at the feet of the master, and
departed marveUing, and disputing vehemently how they were
to carry out the sage's behests, namely how in the case of IV.
they might best make an angle h O n equal to the angle HON
or h O n in I. and III., in the new radiograph that they had it
in their minds to make as Zadig commanded them.
Here the original MSS. becomes indecipherable, and the
question remains. How did they manage to do it ?
To simi up, in radiographing the same part in different people,
with the view of detecting the presence of dissimilarity by
comparison of the members of the series one with another,
I think it could be proved {a) that three things are geometrically
necessary, and (b) that three things are radiographically ex-
pedient : —
(a) I. The Axis must be directed through the same anato-
mical points ; one point is not sufficient.
2. The distance of the radiographic Centre from the
part must be proportioned to the size of the part.
3. The planes of delineation must be parallel.
(b) I. The plates or screens should be at right angles to
the Axis, anatomically defined as above.
2. The distance of the plate or screen from the part
should be as short as possible.
Digitized by CiOOQIC
336 DR. D. S. DAVIES
3. The resulting radiographs might with advantage be
photographically enlarged (or diminished) to the same
scale.
Although no doubt some apology is due from me to the
mathematically inclined for a rather crude exposition of the
-doctrine of similar triangles, I trust this somewhat theoretical
■essay may lead to simpler methods of solving by radiographic
delineation some perplexing clinical problems. Nor am I un-
mindful of the vexatious limitations imposed up to now on the
X-ray worker by practical exigencies pecuUar to the employ-
ment of the Rontgen rays in diagnosis. Yet any fine morning
these technical difficulties may be overcome, and then a correct
system of radiography will become of enormous importance.
The risk of an incorrect system is not so much in missing excessive
enlargement or displacement of parts, as in imagining abnormality
to exist where it does not, or of failing to detect the lesser abnor-
malities. Till such a system be brought into uniform use, the
medical witness would be wise to maintain in a court of law a
'Critical attitude towards radiographs produced for his opinion,
where he has not the means of checking the manner of their
production in regard to the relative positions of Centre, Axis,
Plate and Object.
BIBLIOGRAPHY.
Euclid, Elements of Geometry, Books V. and VI. .
PUBLIC HEALTH IN BRISTOL, 1906-7.
BY
D. S. Davies, M.D.,
Medical Officer o/ Health,
The general health returns, which were very favourable for the
year 1906, have continued to be satisfactory during the first
three quarters of 1907.
The recorded death-rate for the year 1906 was 14.5 per i,qoo.
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ON PUBLIC HEALTH IN BRISTOL, I906-7. 337
compared with a rate of 14.7 for the previous year, and with a
rate for the seventy-six large towns of England and Wales of 15.9.
The rates for the four quarters of 1906, and for the three
completed quarters of 1907, are here shown for comparison : —
1906.
1907.
ist Quarter . . . .
16.84
17.40
2nd Quarter
13.66
12.58
3rd Quarter . . . .
13.10
10.24
4th Quarter . . . ,
14.79
—
The birth-rate for 1906 was 25.8, a decrease on that of the
previous year. This rate has shown an almost uninterrupted
•decline since 1882. The annual marriage-rate is also decreasing.
Infant Mortality. — ^The proportion of deaths of infants under
one year to births in 1906 was 127 per 1,000, which is somewhat
higher than that for the previous year (122). The highest rates
were noted in Bristol Central, 173, St. Philip, 153, and the lowest
in Ashley, 79. The general infantile rate is satisfactory,
•compared with 145 recorded in the seventy-six large towns of
England and Wales, but the most crowded districts are
•susceptible of improvement.
The infant mortality rates for the four quarters of 1906, and
ior the three completed quarters of 1907, are here given for
comparison : —
1906. 1907.
1st Quarter . . . . 148 . . 118
2nd Quarter . . 93 . . 88
3rd Quajrter .... 156 . . 99
4th Quarter . . . . m . . —
The influence of a somewhat damp and cold summer and
'early autumn is apparent in the diminution shown in the third
quarter of 1907, chiefly due to the small amount of infantile
•diarrhoea.
The chief epidemic diseases. — ^There has been no notable
occurrence in regard to these diseases.
Scarlet fever, while still occurring in scattered cases, is generally
of a mild type, and gives rise to Uttle mortality.
23
ToL. XXV. No. 98.
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338 DR. D. S. DAVIES
Diphtheria, while distinctly less fatal than in the period
1900-04, still persists, and occasionally shows severe forms;
but the tendency to form school outbreaks has declined, and
children at susceptible ages appear to have'acquired considerable
immunity.
Enteric fever, — ^This disease only occurred in sporadic form
in 1906, except in the Bristol Central District, where an outbreak
centred round a shell-fish shop receiving supplies from a tidal
river in South Wales. The type of case was severe, but the out-
break did not assume alarming dimensions.
A continuing outbreak at a *' home " in the city is at present
(November, 1907) engaging attention. For some months case
after case has continued to crop up at intervals, in spite of every
usual precaution. The continuance of infection has been clearly
traced to milk, but the source of re-infection of this food has
hitherto been non-apparent. It may possibly be due to a case of
" carrier '' typhoid, and careful observations are now in hand
with a view to confirm or disprove this supposition.
Small-pox, — During the past few years small-pox has adopted
the annual habit of paying the city a tentative spring visit..
The type has continued to be very mild, leading to difficulty in-
tracing out contacts, and to increased chance of missed cases ;
but, on the other hand, the infectivity of this mild type appears
to be comparatively small, and, as a fact, each outbreak has
been readily repressed.
This disease, absent since June, 1905, re-appeared in
January, 1906, lasting up to June, this period affording a
scattered product of twenty-seven cases. 1
The interest of the outbreak centred in its introduction and,,
commencing, spread in a public elementary school, a quite
unique experience in Bristol. Investigation showed that three
out of four children in one class in the school were unvaccinated.
The obvious remedy soon stopped the spread ; but the strictness
of the conditions for success is shown by the necessity of having,
at one time during the outbreak no less than six hundred persons
under observation. This was over by the end of March.
1 Annual Report of Medical Officer of Health, pp. 30-33.
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ON PUBLIC HEALTH IN BRISTOL, I906-7. 339
A second introduction, apparently unconnected with this one,
lasted from March to May, owing to two *' missed " cases, but calls
for no special comment.
From May, 1906, until January, 1907, no fresh introduction
occurred ; in January, however, it re-appeared, and resulted in
five cases, one fatal. This outbreak was blotted out by April,
and no further introduction has taken place.
The summer session of Parliament was distinguished by the
passing of some important Acts bearing on public health.
(i) The Notification of Births Act, 1907. — ^This is an adoptive
Act, and its object is to secure notification of each birth within
thirty-six hours to the medical officer of health, so that advice
may be extended to the mother, where needed, as to the manage-
ment and feeding of her infant. Adoption of the Act in any
district is subject to the approval of the Local Government Board,
who will require to be satisfied that the local authority will provide
the necessary machinery, health visitors, &c., for utilising its
provisions. Some opposition to the Act as it stands has been
in some quarters expressed by the medical profession, who may be
compelled to a violation of professional secrecy ; and in place of
its adoption — at Gateshead, for example — a voluntary notification
by the medical attendant has been substituted.
(2) The Education (Administrative Provisions) Act, 1907,
provides, inter alia, that the powers and duties of a local
education authority shall include the duty to provide for the
medical inspection of children, immediately before, or at the time
of, or as soon as possible after their admission to a public
elementary school, and on such other occasions as the Board of
Education directs ; and the power to make such arrangements
as may be sanctioned by the Board of Education for attending to
the health and physical condition of the children educated in
public elementary schools.
Ths* effect of this Act will be to make universal that medical
inspection of school children which has proved advantageous in
the few districts of England where it has been attempted, and to
bring England into line with the advance in the direction for some
years made in America and upon the Continent.
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340 PUBLIC HEALTH IN BRISTOL, I906-7.
The proviso that in any exercise of powers under this section
the local education authority may encourage and assist the
establishment or continuance of voluntary agencies, and
associate with itself representatives of voluntary associations for
the purpose, is evidence of the value attached by the department
to the assistance which voluntary endeavour, when started in a
friendly spirit, can afford to public bodies in their executive work ;
assistance which is particularly helpful in matters relating to the
care of the young, the assistance of mothers at and after child-
hirth, and the teaching of domestic hygiene.
The Public Health Acts Amendment Act, 1907, contains, in
Parts III., IV. and V., forty-one sections, variously amending
and supplementing previous Acts in regard to sanitary provisions,
infectious diseases, and common lodging houses. The Act may be
applied in part, or wholly, by an order of the Local Government
Eoard to any sanitary district.
The Public Health [Regulations as to Food) Act, 1907. — ^This
short act of three sections implies a good deal more than its
length would suggest. It is entitled ''An Act to enable regulations
to be made for the prevention of danger arising to public health
from the importation, preparation, storage, and distribution of
articles of food." The regulations will be framed by the Local
Government Board under the Pubhc Health (Ports) Act, 1896,
and will materially add to the executive duties and obligations
of port sanitary authorities.
The Cholera Regulations of the Local Government Board,
dated September 9th, 1907, reproduce the main provisions of
previous Orders, with modifications and amendments in accord-
ance with the decisions of the Paris Convention, and giving recog-
nition to the recent developments of knowledge as to rat infection,
plague, and mosquito infection in yellow fever. The Central
Department is fully alive to the necessity for preparation in
advance, especially in view of the possibility of renewed activity
of cholera, and the port sanitary districts are to be maintained
in a proper state of efficiency.
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Iprogress of tbe (TDeMcal Sciences^
MEDICINE.
Course of the fibres of taste. — With regard to the vexed
question as to the course of the taste-fibres, Morriston Davies, in
a very valuable paper on the " Functions of the Trigeminal
Nerve," based partly on experimental evidence, and partly on
the material afforded by fifty cases in which the Gasserian ganglion
had been removed, i brings forward the following evidencie. The
difference of opinion is chiefly as to the connection between the
chorda tympani and the brain, whether taste impulses pass by
the trigeminus or by the facial or glossophar5aigeal route. The
best evidence dealing with the relationship of the fibres of taste
and the trigeminus is derived from the examination of patients
after removal of the Gasserian gangUon. The following table
gives the result in cases examined more than one month after
the operation : —
Taste Taste Taste
Name of examiner. Total cases, unaffected, impaired. lost.
Krause .... 5 .. i ., 2 .. 2
Gushing . . 18 . . 17 . . i
Davies .... 17 . . 15 . . • I . . i
40 •• 33 .. 4 •. 3
Dr. Davies considers that in face of these figures it is impossible
any longer to consider the trigeminus as the normal channel
through which taste-fibres reach the brain. Explanations of the
occasional disturbance, either temporary or permanent, of taste
after removal of the Gasserian ganglion have been attributed to
(i) injury to the superficial petrosal, which connects the genicu-
late ganglion with the glossopharrageal, during the operation or
by subsequent formation of scar tissue ; (2) to injury to cells of
geniculate ganglion (Dixon) ; or (3) to some interference with
chordal (Krause) transmission, brought about by a mechanical
or toxic disturbance due to degeneration of the N. lingualis
(Gushing).
As to the course of the taste-fibres, the author concludes that
cUnically evidence has been brought forward which supports
those who hold the view that the fibres pass by the pars inter-
media, as well as to those who favour the path by the glosso-
pharyngeal, but from morphological, developmental and histo-
logical observations, he inclines to the opinion that the gustatory
1 Brain, 1907, xxx. 219.
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342 PROGRESS OF THE MEDICAL SCIENCES.
impulses reaching the geniculate ganglion by the lingual and
chorda t3mipani, pass thence to the brain in the pars intermedia.
Experimental atheroma. — In view of the cHnical work that has
been done in recent years on estimation of the blood pressure,
and of the importance of elucidating the causes of atheroma and
arterio-sclerosis, the results of experiments made by Dr. G. R.
Rickett are of importance, i The animals used were rabbits,
since by way of the superficial veins of the ear an easy channel
for daily intravenous injections is afforded. The drugs em-
ployed were adrenalin, squill, barium chloride, tobacco and
nicotine.
The experiments show that adrenalin is not the only substance
that can cause atheroma in rabbits, and that the cause of the
disease, if a toxin, cannot be a toxin peculiar to this substance.
The author holds that a mechanical factor, rise of blood pressure,
is alone responsible, and that any procedure which raises the
blood pressure, whether it be physical or the administration of
drugs, provided that the pressure induced be sufficient, will
cause atheroma. In applying these results to human pathology,
it is to be remembered that these animals have only been ex-
perimented with for a few months. In three out of four animals
treated with either tobacco or nicotine the author succeeded in
producing atheroma ; he assumes for the failures that the in-
dividuals had a high resistance to the effect of the drug, and
remarks that other observers have found it difi&cult to produce
the disease in young animals, and also that the more weakly an
animal is the more readily are changes in its vessels produced.
He succeeded in producing atheroma with both barimn chloride
and squill ; with the latter, however, the changes are not so
severe and extensive as with adrenalin, tobacco, nicotine and
barium, but show the same microscopical features. Adrenalin
is by far the most certain agent to produce these lesions ; this
would be expected, if we suppose that atheroma is originated by
the damage done by periods of high blood pressure, for adrenalin
is by far the most potent agent in this respect.
The author thinks there is no evidence to support the views
that the patchy character of the disease is due to the effect of
the drug on the vasa vasorum. Further, a mechanical theory
affords a reason for the affection of the large trunks only, since
it is only in the proximal portion of the vascular system that the
pressure rises high enough to effect so great a destruction of
elastic tissue. The occurrence of small plaques of atheroma at
points of bifurcation, where ascending arteries rise from the
artery, is due to the high blood pressure at this early point of
the course of these arteries. No changes were found in the
1 /. Path, and Bade fiol., 1907, xii. 15.
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MEDICINE. 343
pulmonary artery, because the pulmonary system has no, vaso-
motor nerves, and is but poorly provided with vessels.
Experiments with potassium cantharidate, chosen because it
acts as an irritant but causes no rise in blood pressure, were
negative, thus proving that a merely irritant effect cannot cause
the disease in question. Without going into detail, it may be
said that the earliest changes consist in stretching, frequent
breaking and interruption of the elastic fibres, followed later by in-
volvement of the muscle fibres in the degenerative process, and
deposition of calcium salts. The nearest parallel in human
pathology to the experimental disease is the calcification of the
media in the peripheral vessels, and the most important con-
clusion to be drawn from these experiments is that high blood
pressure certainly causes great damage to the arterial system.
I Chloride deprivation in treatment of renal anasarca. — Prof:
I Strauss 1 says that chloride deprivation is to be used, not as
some have urged for the treatment of diseases of the kidney in
general, but for the prevention and treatment of certain forms
of renal dropsy ; and further, that not every case of renal anasarca
I is necessarily an object for the systematic deprivation of chloride.
i It is in cases especially of acute and chronic parenchymatous-
nephritis that the question of chloride deprivation occurs, whilst
the treatment of dropsy in contracted granular kidney falls into
the same category as that of cardiac dropsy. In anasarca, due
; either to acute or chronic parenchymatous nephritis, this treat-
; ment is indicated. Cases of the latter in which elimination in
general, and more especially that for sodium chloride, is deficient^
can be recognised by two s3miptoms : (i) with an average intake
in the food, the daily output, both per cent, and in total quantity
in the urine, is extremely small ; and (2) running parallel with
this deficient excretion, a progressive increase in body-weight,
indicating a retention of sodium chloride in the tissues, and with
it of water. Without visible anasarca a considerable quantity
of water can thus be held back in the tissues. In this condition,
then, and in anasarca itself, deprivation of chloride should be a
part of the treatment, and is obtained by (i) regulating the
intake in the food, and (2) increasing its elimination from the
body by giving preparations of caffein, of which diuretin is the
most e&ective, increasing both the total quantity of urine and
also the percentage of chloride.
So also Minkowski, writing on the treatment of dropsy by
regulating the intake of water and salt, 2 puts the reduction of
-sodium chloride intake in the first line in the treatment of renal
•dropsy. Limitation of fluid must be carried out with caution.
1 Folia Therap., 1907, i. 122.
2 Therap. d. Gegenw., 1907, n.f., ix. i.
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344 PROGRESS OF THE MEDICAL SCIENCES.
Excessive quantities of fluid are, however, certainly to be avoided,
SO that a diet of milk only — three litres of milk being taken daily
— is a mistake, especially in the contracted kidney. One to one
and a half litres of milk should be given combined with other
articles of diet. It is well known that in renal dropsy, digitalis and
the diuretics belonging to the group of purin bodies — caffein,
diuretin, agurin, theocin — ^are often of great service. They bring
about the ehmination of a quantity of water and salt from the
body without damaging the kidneys. The question cannot,
however, be regarded as yet settled, for Drs. A. Bittorf and
G. Jochmann, in an article on *' Sodium Chloride Metabolism," ^
state that the conditions present in renal disease are very variable.
If cardiac failure is present, the conditions are the same as in
uncompensated heart disease. The elimination of chloride is.
good, and to a great degree independent of the excretion of
water. By increasing the amount of salt taken in acute nephritis
with oedema there was brought about an increased output of
sodium chloride and water, and afterwards the same patient, when
without oedema and with good excretion of water, sometimes
showed a delayed excretion of chloride. In chronic parenchy-
matous nephritis, there is very good, seldom delayed elimination
of chloride with normal output of water. In chronic interstitial
nephritis there is generally good chloride excretion.
J. MiCHELL Clarke.
SURGERY.
Excision of the breast for carcinoma has been attended by
better remote results since the adoption of wider removal of skin
and lymphatics than was formerly the custom, but there is still
much to be accomplished in combating this disease by operation. To
those who have not familiarised themselves ^vith modern methods,,
excision of the breast seems simple enough for anyone to under-
take, but the results under these circumstances are deplorable.
Several papers have recently been published dealing with this
subject, and a consideration of them will show the practice of
to-day and the results to be anticipated. At the Massachusetts
General Hospitals there were 416 cases of primary operation for
cancer of the breast during a period of ten j^ears, and of these 376-
were traced to a conclusive end-result at an average period of eight
years after operation. Sixty-four cases were alive and well,,
and seven died without recurrence over three years after the
operation. Counting in the operative mbrtality, there were
320 attempts at radical cure, 67 of which, or 20.9 per cent.,,
were successful. Cases in which the tumour was ulcerated, or
was adherent to the skin or chest wall, and cases in which the
1 Deutsches Arch. f. klin. Med., 1907, Ixxxix. 485.
2 Surg., Gynec. and Obst., 1907, v. 39.
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SURGERY. 345
axillary glands were palpably enlarged, gave distinctly less
promising results than when these conditions did not exist ; and
no case with palpably enlarged cancerous glands above the
clavicle, and no case of cancer of both breasts, was cured. It
was found that extensive operations with wide removal of skia
gave the greatest freedom from local recurrence, but removal of
the pectoralis minor appeared to be of slight significance. Re-
currence in the scar occurred in less than half the cases. Internal
recurrence was most frequent in the lungs, mediastinum, in the
axillary and supra-clavicular glands, the liver, and the spine..
Nineteen per cent, of those passing the three-year limit without
evidence of recurrence, showed recurrence later, and four cases-
developed recurrence six years or more after the operation..
Fifteen cases died as an immediate result of the operation, giving
a mortality of 3.6 per cent, on the whole period of ten years ; but
the mortality was 5.1 per cent, in the first five years, and 2 per
cent, in the last five years. The results which we have just sum-
marised represent the work of twenty different surgeons, and may
therefore be regarded as the probable outcome of any large number
of cases. Greenough, Simmons and Barney, 1 who have collected
these cases in the practice of the Massachusetts Hospital, regard
a '* complete operation *' as one including the removal of the
whole breast and axillary contents, the removal of the pectoralis-
major muscle, and either division or removal of the pectoralis-
minor. They rightly consider that the amount of skin removed
with the breast is a matter of great importance. They contrast
the cases in which the wound was directly closed by suture with
those in which so large a skin defect was made that a plastic
operation was required to close the wound. In 67 out of i60'
"complete operations'' a plastic operation was performed. Of
this number 13 were successful, 19.4 per cent. ; whereas in the
93 complete operations in which the wound was sutured directly
there were only 11 successful cases, 11.7 per cent. The difference
between these cases was even more marked when local recurrence
was considered. Of the 67 cases with plastic operation, no local
recurrence in the scar took place in 57.6 per cent., whereas of the
complete operations in which the wound was sutured directly,
only 44 per cent, remained free from local recurrence.
Having thus considered the results obtained at a general
hospital, we may refer to some points in the methods and results
of individual operators. Halsted^ for the past two years has
performed the ** neck operation '* (clearing out the lymphatics
above the clavicle) in most cases. He omits it in hopeless cases,
in most *' duct cancers,'' and in some carcinomata of adenomatous
type in which the axilla at operation is not macroscopically
involved. Unless there are special contra-indications, he con-
siders the neck operation should be performed (i) in all c^^-ses with
1 Loc, cit. 2 Ann. Surg., 1907, Ixvi. i.
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346 PROGRESS OF THE MEDICAL SCIENCES.
palpable, operable, neck involvement ; (2) when the apex of the
surgical axilla is involved. When mid-axillary involvement is
•demonstrable at the operation apical implication is almost certain,
and hence (3) in these cases also the neck should be typically
•cleared of its l3miphatics, as high, at the very least, as the bifurca-
tion of the carotid. The influence of early operations and glandu-
lar involvements is shown by the fact that he claims a cure of 85
per cent, if the axilla and neck are negative, of 31 per cent, if the
axilla is positive and the neck negative, but only of 10 per cent,
if both axilla and neck are positive. In considering these statistics
Halsted takes the three-year limit as evidence of cure; but
Jacobsoni considers that this limit is too short to determine the
•end-result. This observer follows Halsted's technique except as to
the removal of the supra-clavicular glands, which is only under-
taken when there has been apparent invasion of the neck.
Oliver^ considers that the most potent factor bearing upon
prognosis is the character of the growth. The richly cellular,
rapidly growing, soft, succulent carcinomata are much less
amenable to surgical treatment, even when seen early in the
course of the disease, than are the more fibrous, slowly growing,
hard varieties of the disease,
Cabot 8 draws attention to the danger of recurrence from the
self-inoculation of the wound with cancer cells set free during
operation. The possibility of this occurring is a reason for re-
moving breast, muscles and axillary contents in one mass, and
for keeping the dissection outside of the lymphatic distribution
as far as possible. When a cancer has been cut into for purpose
of diagnosis, the opening should be tightly closed before further
operation is undertaken, and every precaution should be taken
by changing instruments, &c., to avoid inoculation. Where the
operation has gone close to the cancer, as through suspicious
tissue, Cabot thinks that the application of tincture of iodine to
the surface of the wound prevents a quick recurrence when such
appears otherwise inevitable. This observer, in common with
others, makes it a practice to give each patient a course of X-ray
treatment immediately after the operation, with the idea of
destroying any bits of cancer that may have escaped removal.
For this the exposures to the X-rays are made twice a week for
three or four months after operation.
One of the most enthusiastic supporters of clearing the
supra-clavicular region as a routine measure is Pilcher,* who
finds that in ten of the cases in which enlarged supra-clavicular
nodes were discovered and removed, three remained free from
recurrence. He considers that the point of suspicion is the
triangle at the junction of the subclavian and internal jugular
veins, where the nodes are found which guard the entrance to the
1 Ibid., p. 43. 2 Ibid., p. 51. ' Ibid., p. 57.
* Ibid., p. 67.
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SURGERY. 347
mediastinal lymphatic paths, and to which run not only the
lymphatics, which pass up under the clavicle from the axilla,
but also an inconstant but not infrequent set of ducts, which
run up in the front of the thorax from the mammary region to
the base of the neck, down into which they dip after running
over the inner end of the clavicle. The denseness of the deep
fascia at the base of the neck, together with the overlying tissue,
make it difficult to detect infected nodes by palpation until they
have attained some size ; but when palpable or visible, the
presumption is that the infection is of long standing and of con-
siderable extent, and therefore justifies the gravest prognosis.
Pilcher thinks that even then the infection may still be confined
to the accessible supra-clavicular group, so that their extirpation
may ensure a complete removal of all carcinoma-bearing tissue ;
but of more importance is the practical recognition of the proba-
bility of the presence of infection of the supra-clavicular nodes
in every case of breast carcinoma of . much duration or extent,
and the incorporation into the general plan of operative attack,
in all such cases, of an incision into the base of the neck and a
systematic removal of all possibly infected tissue, even though
there may be no distinct evidence to sight or touch before such
incision of the presence of the infection.
From a careful study of fifty cases, Dennis i states that after
an apparent cure for eighteen years after operation there may
yet be a return of the disease in some other organ. In the cases
in which no return has been observed, the operation was per-
formed almost without exception within six months of the
incipiency of the disease, thus showing the importance of early
operation. He, however, points out the fact that in some cases
in which the outlook is most unfavourable, as manifested by
•extensive ulceration, hemoiThage and wide-spread axillary in-
volvement the final results have been entirely satisfactory.
Enough has been said to show that the operation for removal
•of the breast for carcinoma should not be entered upon without
an intimate knowledge of modern principles ; and one may call
to mind the statement of Ransohoff 2 that '' almost everyone
who does surgery at all feels himself competent to do a breast
operation, which to do properly, in my judgment, is one of the
most difficult feats of surgery." From the extracts which we
have quoted it can be seen that there is complete unanimity as
regards the removal of a wide area of skin, the pectoralis major
and the axillary lymphatics. The chief point of difference is as
regards the desirability of removing the lymphatics above the
clavicle as a routine measure. Some observers state that they
always consider this necessary, but it must be remembered that
this procedure increases the mortality of the operation. The
^ser course perhaps is to be guided by the actual conditions
1 Surg., Gynec. and Ohst., 1907, v. 57. a Ann. Surq., 1907, xlvi. 7$.
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found at the time of operation, and to remove the lymphatics-
above the clavicle if they are obviously affected, or if the axillary
group of glands is affected so high up as to suggest the proba-
bility of the infection of the supra-clavicular lymphatics.
As Oliver! truly says, the operative treatment of cancer of
the breast is far from an ideal method, even with the extensive
removals practised at the present time ; but the hope for the
future lies in better prophylaxis, and in a better knowledge of the
nature of the disease.
James Swain.
PSYCHIATRY.
Bacterial origin of general paresis. — ^Few investigations into
the pathology of insanity have been followed with more interest
than those of Ford Robertson and McRae^ , deahng with a bacterial
origin for general paralysis of the insane. These authors assert
that a diphtheroid bacillus — ^perhaps an attenuated form of
Klebs-Loffler bacillus, but more likely a distinct form — ^is the
specific organism in general paresis and tabes. The invasion of
this is specially predisposed to by syphilis, chronic alcoholic
excess, and over-nitrogenous ingestion. Large numbers of
a diphtheroid bacillus are said to have been found in the respira-
tory, alimentary and genito-urinary tracts of advancing cases of
general paresis, the principal infecting sites being considered ta
be the buccal and naso-pharyngeal mucosae. From these foci
toxines are generated which occasion the facial tremors and
paresis, and by perineural conduction some of the cortical lesions
also. Stress is laid on the . actual tissue-invasion by these
organisms in general paresis as distinct from their finding on the
surfaces of mucosae, which may happen in other cases than general
paresis or in sane individuals. The authors describe especially
two forms of diphtheroid organism, one often a thread-Uke
bacillus which they term B. paralyticus longus, commonly the
only micro-organism found in the catarrhal pnemrionic foci that
occur, in most of the cases of general paresis dying during con-
gestive seizures. A second form of diphtheroid bacillus, which
resembles the B. xerosis in broth reaction, but differs morpholo-
gically in showing prominent metachromatic granules, is not
thread-like, and is thinner and shorter than the other ; this they
call B. paralyticus brevis. Both forms are often virulent to
mice and rats, but there is a variance in their relative toxicity.
The B. paralj'ticus brevis has been detected in fresh blood in one
case of general paresis, but is said to be taken up so rapidly by
the polymorphonuclear leucocytes, that complete digestion
occurs in two to three hours. This bacteriolytic power of the
leucocytes in general paresis, the authors think, shows a higher
index than in the normal individual, and it is owing to this, in
1 Loc. cit. 2 y. Mant. Sc, 1907, liii. 590.
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PSYCHIATRY. 349
Ihe greater number of cases, that it is not practicable by present
methods to procure cultures during hfe. They, however, made
pure growths of a diphtheroid bacillus from fresh blood in four
cases and from cerebro-spinal fluid in two. Disintegrating
bacilli were found in the blood, cerebro-spinal fluid, urine, vessel-
walls and pia-arachnoid of general paresis in many cases. Their
experiments on rats gave varying results according to the in-
oculation with the long or short form of the diphtheroid, and the
isolation of these from dead or living tissues. Those rats which
died with paralytic symptoms presented changes in their cerebral
tissues in the form of periarteritis, neuroglia-proliferation and
nerve-cell lesions. Robertson and McRae believe there are two
varieties of general paresis similar and yet essentially distinct,
occasioned by one or other of these bacilli, or perhaps by yet
another form, or forms, of diphtheroid bacilli, gaining entrance
to the lymph stream and blood. They lay stress on the benefit
iound in a case of tabetic crises, in whom injections were at first
made of definite doses of a killed culture of the B. paralyticus
brevis (isolated from the patient's urine), and subsequently of a
bactericidal serum. The first injections were followed by the
return of the crises, which seemed to be immediately dependent
on them. The aim in these researches being a therapeutical one,
experiments were commenced with an anti-bacterial serum,
prepared by inoculating sheep with dead cultures of the B.
paralyticus longus. The immunised serum was given either by
hypodermic injection, by mouth, nose, or in one case per rectum.
Previous inoculations with vaccines, prepared by suspension of
the bacilli in sterile saline solution, gave encouraging results.
Thirty-four cases of general paresis were treated with anti-sera,
and in all what was considered a diagnostic reaction for general
paresis and tabes obtained. This consisted in a rise of tempera-
ture to 100° F. or more (or 99° F. or more when given by mouth),
occurring within twelve and over within twenty-four hours in the
case of injections. Besides this there were flushings, vertigo, defect
of vision, confusion, increased inco-ordination, &c. Control ex-
periments were made in other forms of insanity, and in these no
specific reaction was observed after mouth administration, and
any rise of temperature after injection was explicable by other
factors. (This quahfication hardly appears satisfactory to us.)
Leucocytic increase after the anti-sera was found in most cases
of these controls, but there was no material change in the paretics.
On the other hand, normal serum and polyvalent anti-strepto-
coccal sera were injected into general paretics without reaction.
The authors claim that most of their cases of general paresis
treated with the sera undergo more or legs improvement ; thus,
of 12 cases treated by themselves all improved ; of 9 cases
treated by others 6 improved, 3 did not. This leaves 13 cases
unaccounted for.
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George Robertson, of Stirling, has carried on investigations
with the same objective, but with yet more elaborate precautions
and technique. In thirteen general paretics he found present a
constant diphtheroid organism in seven, and he obtained cultures
from the blood in seven cases and from cerebro-spinal fluid in
four cases.
Thus, not only were cultures more frequently obtained than
by Ford Robertson and McRae, but the organism was studied in
more than twenty cultural media. Moreover, the bacillus
described by the latter authors had not been observed by him
in any case, and the organism which he had found differed from
it in many respects. It also had been found in other forms of
insanity in acute cases. G. Robertson thinks it possible that
a large group of diphtheroid bacilli may exist which produce
substances toxic to the nervous system, and which, if not specific
in producing general paresis, may be contributory.
Orr and Rows hold that infection in general paresis, bacterial
or toxic, proceeds along the l3miph paths rather than the blood
stream. Candler, working at the Claybury laboratory, quotes
various bacteriologists as showing that diphtheroid organisms,
in the first place, are met with adl over the body in cases free
from insanity ; further, that organisms similar to those described
by Ford Robertson are met with in two localities, especially
mentioned by this author, in a large number of sane persons;
that diphtheroid organisms are, as a whole, met with in no
greater frequency in general paretics than in other forms of
insanity, and cannot be isolated more readily from the one than
from the other.
Candler has examined the blood of twenty-four general
paretics during life — on forty-one occasions in all, and in no
single instance has he seen or obtained cultures of an undoubted
diphtheroid bacillus. Also, in nine cases in which he has
examined the cerebro-spinal fluid, he has neither seen diphtheroids
nor obtained cultures. He comments on the dangers of con-
tamination during culture making, the doubtful evidence of
stained films and sections unless confirmed by cultures, and the
errors caused by terminal and post-mortem invasions
Lewis Bruce has found hyperleucocytosis in what he terms
bacterial toxic insanities, and also, variably, in general paresis.
This increase, together with certain temperature rises — ^regular,
recurrent or irregular in type according to the stage of the disease
— with disturbances of alimentary tract, certain serum agglutina-
tions, with signs of a general toxic invasion and lowered leucocytic
resistance, leads him to consider general paresis as a disease of
bacterial origin. He has found, in three or four cases, serimi
taken from general paretics in a stage of remission to arrest the
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PSYCHIATRY. 351
progress of early paretics. One patient he immunised to the
Ford Robertson. diphtheroid, and completely stayed the course
of the disease ; death occurred ere long from phthisis. Bruce
recognises, however, that severe attacks of erysipelas, carbuncle,
&c., may also indefinitely cause an arrest.
It will be seen that so far there is not much unanimity amongst
different observers as to the existence or determination of the
bacterial organism in general paresis. Nevertheless, undoubted
progress is being made in an investigation of immense difficulty,
and the results of Ford Robertson's serum treatment cannot but
be viewed ^vith hopeful bias. That such advance has been made
since 1894, when an article by Goodall and Bullen reviewed the
then meagre literature, and to some extent forecast the present
attitude towards general paresis, is productive of a reasonable
expectation that the further researches of Robertson and others
may end in a solution of a most involved question.
Pomeroyi has contributed very interesting and important
evidence as to the value of lumbar puncture in the diagnosis
of syphilis, general paralysis and some other conditions. The
presence or absence of leucocytic and albumin increase, separate
or conjoined, in the cerebro-spinal fluid appears to give much
help, under known conditions, in the determination of these
diseases. The number of experiments collected and personally
made by Pomeroy are sufficiently harmonious in result to make
his conclusions of considerable weight. Leucocytic increase
seems almost the rule in secondary syphilis ; in the tertiary form
not so surely, unless the nervous system be involved. The
amount of increase is, however, seldom so great in syphilis as in
general paresis, nor is the albumin content, even if at all present,
in the former nearly so abundant as in the latter. The estimation
of albumin is considered a most important matter in deciding
on the presence of general paresis, and is in many cases the only
feature that will differentiate it from syphilis. Albumin increase
is, however, not so constant as hyperleucocytosis, nor is it always
parallel with it. The whole clinical picture of a doubtful case
must, of course, be carefully studied ; but in such, where the poise
of opinion is between brain syphilis and general paresis, a relatively
small cell increase and low albumin content may justify decision
for the former. On the other hand, a negative finding of leuco-
cytic and albumin increase is of more value in deciding against
syphilis and general paresis than a positive one is for them.
Hyperleucocytosis in general paresis has been observed in
nearly all of 500 cases, lumbar punctures giving negative results
of only 2.6 per cent., after due allowances have been made.
Pomeroy himself in thirty clear cases of general paresis found
1 /. Nerv. 6- Ment. Dis., 1907, xxxiv. 312.
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positive increase in cell and albumin in every case. (In about i
half of these he believes syphilis to have been present.) His
•opinion is that these conjoined positives constitute one of the
earliest and most constant signs of general paresis, even appearing
before amnesic, eye or ataxic symptoms.
Farrar regards the hj^perleucocytosis as the outcome of a
subacute or chronic cerebro-spinal periarteritis or pia-arachnitis.
Further experiments have been made to ascertain the value of
this cell and albmnin content in the differentiation of chronic
alcoholic psychoses and other central organic brain troubles.
Nissl collected and examined thirty cases of presumed chronic
alcoholic psychoses ; in twenty-three of these the finding was
negative ; the others proved to be either actual or probable
paretics or old syphilitics. Other observers have recorded similar
results. The finding in epilepsies is usually negative, except
where there is a syphilitic basis ; the same is said of brain tumour,
arterio-sclerotic insanity, Korsakoff's disease, central hemorrhages,
dementia precox, and paranoidal excitement. In short, a
constant absence of hyperleucocytosis practically negatives brain
•syphilis and para-syphilitic conditions. On the other hand, the
differentiation of brain syphilis and general paresis will have to
rest on the relative amount of hyperleucocytosis and albumin
association.
Pomeroy insists on the necessity of several punctures before
•decision be made. The dangers of the operation appear minimal
if not more than 3 to 5 c.c. of fluid are withdrawn ; it is,
however, counterindicated in cerebellar tumour. The patient
should not be punctured unless put to bed ; in this case mild
headache, nausea or vomiting seem the only sequelae.
Change in type of general paresis. — Clark and Attwoodi have
■collected 3,000 records of general paresis, to investigate the
question of a change in its type. They assert that the oft-stated
opinion that there is a relative increase lof the simple demented
and melancholic type to the grandiose in late years is mainly
due to the inclusion of cases of dementia, depression, and cerebral
syphilis, formerly wrongly classified, but now correctly grouped
under general paresis. These authors consider euphoria still to
be the characteristic psychical S3miptom, and to be found in
70 per cent, of the cases, although less extravagant and grotesque.
Allowing for the more rigid delimitation of pseudo-general
paretics, the writer of this periscope has seen no reason to alter
the conclusions expressed by him in 1893 on this variation in
type — at any rate, so far as England is concerned. He still
asserts that mania is relatively less frequent, less pure and less
.sthenic ; that primary dementia is more common ; convulsive
1 /. Nerv, 6- Ment, Dis,, 1907, xxxv. 553.
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REVIEWS OF BOOKS. 333
and paretic seizures less frequent, less violent and fatal. The
variations are much influenced by locality, and the strenuous life
and fresh population of the American cities quite accounts for a
maintenance of the former characteristic type there. It is
likely,'On the other hand, that any gradual process of degeneration
taking place in a nation is reflected in the type of its insane as well
as its sane population.
F. St. John Bullen.
•Reviews of »oohs^
Aids to Medical Diagnosis. By Arthur Whiting, M.D. Pp. ix.,
152. London : Bailliere, Tindall & Cox. 1907.
This little book is intended for those who already possess a
knowledge of systematic medicine. The plan adopted has been
to start with the prominent symptoms in any given case, and then
to separate the members of each group as clinical entities. The
book therefore is essentially clinical in its aim, and the writer has
succeeded in compressing a large amount of useful information
into a small compass.
Aneurysm of the Abdominal Aorta. By F. P. Nunneley, M.D.,
M.A. Pp. vii., 121. London : Bailliere, Tindall & Cox,
1906.
The author has published this monograph, originally written
as a dissertation for the M.D., partly at any rate at Professor
Osier's suggestion. It consists of a careful analysis of thirty-
two cases, the clinical and pathological notes of which were
found in the records of St. George's Hospital ; and though little
is unearthed that has not been taught before, yet the book is of
much value in several ways. It is in the first place a check on the
statistical articles already published by Browne, Bryant and
others. Again, several interesting aetiological data are brought
into prominence, notably the rarity of the condition in women
and the comparatively early age at which its victims are affected
(between 25 and 45 in 75 per cent.). Only thirteen of the cases
were correctly diagnosed during life, and some of Nunneley's
observations on diagnosis are therefore of peculiar interest ; in
particular there is his remark that radiography is only of value
in confirming a positive diagnosis. Perhaps the most important
section is that dealing with treatment. It is naturally pessimistic
in tone, perhaps unduly so in the paragraph dealing with
24
Vol. XXV. No. 98. Digitized by
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354 REVIEWS OF BOOKS.
potassium iodide. Lancereaux's gelatin treatment is also described
as unsatisfactory. The results of surgical treatment, bad as they
have been hitherto, yet leave room for hope as to the future.
Apart from its intrinsic worth, this monograph is an eloquent
testimony to the value of honestly-kept records, whether clinical
or pathological ; and its author is to be congratulated from all
points of view upon this solid addition to our knowledge of aa
interesting and important subject.
Manual of Anatomy. By A. M. Buchanan, M.A., M.D. Vol. 11.
Pp. XV., 575 — 1539. London : Bailliere, Tindall & Cox.
1907.
It is impossible to review in any detail a book of over 1,500
closely printed pages in the space at our disposal. This volume
deals with the abdomen, head and neck, and thorax, and is
published in the same style and in series with Rose and Carless's
Surgery. It forms a much less cimibrous book than any of the
single-volimie anatomies, and is printed clearly and illustrated
well. The regional method of description is adopted, which,
together with some directions for dissection, makes the book a
manual for the dissecting-room as well as a systematic treatise.
There can be no doubt that the whole work being by the same
hand is an advantage far greater than any obtained by the
system of multiple authors in such a subject as anatomy. The
letterpress and descriptions are extremely clear and accurate ;
but it is to be regretted that not only are the well-known personal
names, such as Scarpa's or Cotle's fascia, retained, but many
others which are new to English students are introduced, such as
Houston's muscle for the anterior part of the bulbo-cavemosus.
and the muscle of Guthrie for the constrictor urethrae. This
involves an unnecessary effort of memory in a subject which
already taxes that faculty to the utmost.
The manner in which the embryology and histology of each
organ are described after the gross anatomy is completed is a
most excellent plan, and one which almost compels the student's
attention, whereas separate chapters of these subjects are apt to
be overlooked or forgotten. The illustrations of the abdomen,,
thorax, and nervous system are very clear, and just fulfil the
purpose for which they are intended. But many of the pictures
of the head and neck are far too small and complicated, and
would necessitate a reference to larger text-books or atlases.
Taken as a whole, the book is a fresh and clear exposition of
an intricate subject, and it will probably be welcomed for its
conciseness and become as popular among students as the-
other members of the same series of manuals.
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REVIEWS OF BOOKS. 355
Inflammation. By J. George Adami, M.A., M.D., F.R.C.S
London : Macmillan & Co. 1907.
It was a happy thought which led Professor Adami to issue
this reprint from his article on "Inflammation" in Allbutt's
System of Medicine. Admirable as the original contribution was,
the issue gains by the inclusion of the more recent work on the sub-
ject. Would that the book could find its way to the desk of every
writer upon medical matters, and form a part of the outfit of all
who carry out the practical applications of medicine and surgery 1
" It cannot be too strongly emphasised," says Adami, ** that
a knowledge of the inflammatory process is the foundation of all
pathology; and if our pathology is not to be a mere catalogue
of names of morbid states, but an endeavour to bring into order
and relationship the phenomena of disease, then the study of
the inflammatory process is the natural starting-point for a right
understanding of pathology and what it can teach us.
** It is deplorable that many surgeons enunciate a pathology
at variance with that of the physicians ; it is a matter for regret
that general pathology and bacteriology are so rarely associated
in one worker ; but it must be acknowledged that no one man
can hope to be equally familiar with the recent advances in
neuropathology, haematology, immunity, infection, &c."
Hence the status of this book is at once defined. It marshals
the facts already known ; it states the deductions permissible,
and points the way to further work ; it tends to unify the termin-
ology and the conception of inflammation ; and as such, it
shoidd have the careful study of every student of medicine and
surgery.
We are not going too far when we point out that in no other
book is the subject so concisely and clearly set forth, and when we
indicate that our lack of knowledge of its contents must stamp
us as too little caring for the health of our patients ; for Adami
has not contented himself with the enunciation of principles, but
has troubled to apply these to therapeutical details.
The Bacteriological Examination of Water Supplies. By Wm.
G. Savage, M.D., D.P.H. Pp. xvi., 297. London : H.
K. Lewis. 1906.
The objects of this class of book are two : first, to provide
the reader with an up-to-date compilation of methods and of
the facts the application of those methods have elicited ; and
secondly, to present the views of the author and of other observers
upon the deductions which may properly be drawn from the
results obtained in dealing with new material. In the present
instance, as may be anticipated from Dr. Savage's wide experi-
ence of bacteriological methods, the first object is very completely
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attained, and the practical worker will be very grateful for the
collection, in so small a compass, of all really useful existing
processes for the detection and enumeration of those micro-
organisms, the presence of which in potable water is a more or
less conclusive indication of pollution. This portion of the book
would be improved by avoidance of a good deal of repetition,
which renders reference difficult, and by a more systematic
display of the essential characteristics of allied species.
With the discussion, however, of the precise significance of
the presence or absence of certain forms, matter of much more
controversial type is introduced.
The author's attitude on this question is not a doubtful one ;
in parliamentary parlance he is a '* whole hogger," as witness the
claim that " it — i.e. bacteriological examination — is taking its
rightful place as the most valuable of all available methods by
which to judge the purity of a water supply,*' and the declara-
tion that " the B. coli estimation is the essential enumeration
upon which to judge the purity of waters." Do the facts justify
quite so emphatic a statement ?
Whilst characterising as baseless the opinion that B. coli is
ubiquitous, the writer adduces proof that it is present in the
excreta of practically all vertebrates, and concludes that " ob-
viously, with such an extensive natural habitat, this organism
must needs be extensively distributed.'* Evidence of this is
afforded by the demonstration of B. coli *' in as little as 2 c.c. of
upland surface waters, even from sources of undoubted piu-ity,
and away from all human or sewage pollution,'* and again by
Dr. Houston in the water of remote Highland lochs, in which
instances its presence is explained by the intervention in the one
case of sheep, and in the other of trout and other ** lower
animals ; '* an explanation that would seem to suggest that the
detection of B. coli must be accompanied by an inspection of
the locality before any definite conclusion can be arrived at.
It appears to be part of the case of the advocates of one kind
of water examination to depreciate all other methods, and Dr.
Savage does not fail to make a determined attack on chemical
processes, adducing the Bridgend epidemic as a case in point.
But the bearing which the source of the water has upon the
selection of the appropriate method of analysis is hardly suffi-
ciently recognised. It is, no doubt, perfectly true that a much
smaller admixture of sewage with water can be recognised by
bacterial than by chemical analysis, but it does not follow that
the former must invariably be the best guide to the recognition
of " impurity and hazard *' under the conditions of natural
water supplies.
When the sewage is directly introduced into and uniformly
mixed with the water, and conveyed to the consumer along a
capacious channel, whether superficial or subterranean, bacterial
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REVIEWS OF BOOKS. 357
examination is, beyond doubt, the most useful aid to topographi-
cal inspection ; but when the polluted water undergoes more or
less perfect purification by subsoil filtration, the arrest of the
micro-organisms is very capricious and uncertain, depending on
the subsoil conditions of the moment, and these do not affect the
presence of the j^erfectly characteristic soluble matters on which
the chemical analysis depends. In such cases bacteriological
enumeration may, and often does, afford no glimpse of the warn-
ing of danger which chemical analysis discloses with certainty.
On the whole, it may be said that Dr. Savage offers no good
reason for abandoning the very generally accepted and safe posi-
tion that all available means should be used simultaneously in
forming an opinion on so vital a matter as the safety of a water
supply, but furnishes one of the best and most useful guides to
the intelligent handling of the undoubtedly important instrument
so ably advocated in the work under review.
Elements of Physics for Medical Students. By Frederic J.
M. Page, B.Sc, F.I.C. Pp. xvi., 288. London : Cassell
and Company, Limited. 1907.
The author describes this volume as a text-book which, in
conjunction with the Manual of Chemistry by Luff and Page,
recently noticed in our columns, serves to cover all the chemistry
and physics — ^both theoretical and practical — required by the
Conjoint Board and the Society of Apothecaries. In reality it is
a well -illustrated syllabus, and excellently adapted to the needs
of the teacher, and just sufficient to refresh the mind of the apt
and well-taught student. Without simultaneous expansion, by
precept and practical demonstration, it would be unintelligible
to the beginner in the science of physics. Of this no doubt the
author is well aware, but the claim to be a text-book is scarcely
justified. On reading the book, one is impressed with the naked-
ness of our school education of the present day, which sends boys
into the study of medicine ignorant of the simple principles of
physics which this syllabus includes, and makes it necessary to
spare some of the all too short five years' curriculum in teaching
such rudiments of knowledge (we forbear to designate it as a
special branch of learning) as can readily be grasped by any boy
of thirteen not deficient.
It is incredible that a youth can register as a student of
jnedicine ignorant of the facts contained in this superficial
survey, which after all includes nothing but a few of those
generalisations based on observation which pass under the name
of laws, e.g. Boyle's Law, Avogadro's, Gay Lassac's, Ohm's,
and the like. Still, we must take our author's word for it, this
kindergarten standard is the one required by our chief examining
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boards. From this point of view, it must be admitted that most
of the statements in the book are accurate, for to have misquoted
the " laws of reflection " would be scarcely possible, and the whole
work is little more than a series of such quotations. In many
places brevity has proved the handmaiden of obscurity, above
all in the chapter where it was least excusable, that on " Light."
The explanation of the diopter is an example of a sentence so
compressed as to defy unravelling ; one must merely begin afresh
and make a new statement in order to be intelligible to the
unlearned.
There is also a poor little sentence crying in the wilderness,
saying, ** Concave lenses would be — 2 D, etc." Disowned by
the context on either side, it is difficult to fill up the hiatus of
that " &c." Myopia is undoubtedly described misleadingly,
being attributed entirely to defects of the lens when no theory
of causation need have been introduced.
Acoustics merely left us wondering — thirteen and a half pages
wasted ! Here even the supposition that the volume might prove
useful as a syllabus in the hands of the teacher failed ; but we began
to appreciate why the art of auscultation and percussion is so
mysterious to the average student, and that to try to build up a
superstructure of knowledge on a foundation is a task fore-
doomed to failure.
As a mere outline of Mr. Page's course of instruction we say
no ill of it, but as a student's hand-book it is not worthy of
consideration.
The British Pharmaceutical Codex : An Imperial Dispensatory,
Pp. X., 1,422. London : The Pharmaceutical Society.
1907.
The second title of this work has been placed first as it most
aptly sums up its function.
The word Imperial may well be used, for the Codex includes
monographs not only on the drugs now official in the B.P., but
also those used in our colonies and dependencies the world over.
Thus while, of course, Calumba and Chirata will be found in
alphabetical order, so also appear Coscinium and Andrographis
for the benefit of the practitioner in India and the Malay
Archipelago. The book is issued by the authority of the
Pharmaceutical Society of Great Britain, and is the work, during
the last three years, of a committee including the leading
pharmacists of Great Britain, while Dr. W. E. Dixon, the
Professor of Pharmacology at King's College, Oxford, has
arranged the concise notes on the Physiological Action and on
Prescribing.
The book is intended to meet three great wants not met by
the British. Pharmacopoeia.
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First of all it includes a large number of drugs and prepara-
iions which, while in every-day use, have not yet been
•considered worthy of a place in the B.P. A national phar-
macopoeia is almost necessarily conservative ; this dispensatory
is liberal to a degree in its admission of new — relatively
new — drugs and preparations. Examples of new drugs in-
cluded are cacodylic, formic and glycerophosphoric acids, salts
-of these acids, and preparations made from them. In this
category adrenine and three liquors prepared from it will
certainly attract notice, in view of the widespread use of
preparations of the adrenal glands, and the difficulty of knowing
what is the best preparation to use. Emulsio chloroformi will
appeal to the medico who does his own dispensing, by economising
Ms use of alcohol for making spirit of chloroform. Emulsio
magnesiae, which will be better known by its synonym of lac
magnesiae, is wanted every day as an antacid, and also as a mouth
wash. The old concentrated infusions — strength 1-7 — we find
liere, and will quite obviate the use of the rather f clumsy
concentrated liquors of the B.P. Solutio saponis aetherea will
enable the member of a hospital staff to obtain the same ether
soap for his bag that he uses at the hospital.
The second innovation made by the Codex is that of intro-
•ducing absolutely new classes of preparations, characteristic of
elegant pharmacy, and also of general medical and surgical interest.
Balnea, gelatin capsules, carbasus (gauze) plain and medicated,
will enable the surgeon to order, and the pharmacist to
supply, articles of known and standard quality ; lints, elixirs
which will obviate the resort to American dispensatories for
elegance of compounding ; gargles, gelatines, guttae. insufflationes,
linctus, misturae, nebulae, parogens, tabellae, tablettae, will, it is
safe to prophesy, go far towards rendering uniform the hospital
pharmacopoeias of the future, in which it will be possible to
include mist, gentian acid, B.P.C., the due inclusion of the last
three letters indicating the source of the formula.
The third function which this work is destined to achieve
may in many respects, and possibly from the standpoint of
the prescriber in all respects, be the most important. Up to
the present every post encumbers the prescriber's table, and
later his waste-paper basket, with more or less plausibly-worded
advertisements of ** new drugs," mostly chemicals of the organic
type. In this flood of patented nostrums it is almost impossible
to separate good from bad, and even when conviction of the value
•of a drug or its preparation is reached, one is confronted with the
necessity of prescribing a patent article more or less ** secret " in
its nature. Add to this that many drugs of this nature — practi-
<:ally identical in composition — appear under a number of different
patent names, and the unsatisfactory position of the prescriber
is emphasised. For example, hexamethylenetetramine may be
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prescribed as aiiiinoform, ammonio-formaldehyde, ammonalde-
hyde, cystamine, cystogen, formin, metramine, urisol, uritone,
urotropine, and vesalvine (one of these names at least being of
Bristol origin). In cases such as this the compilers have coined
a name for the drug — formamine in this case — indicated its
formula and characteristics, and inserted at the end of the
monograph a list of patent names under which it is known.
Further examples are acetannin, tannigen, methyl ditannin,
tannoform, sodii anilarsenas, atoxyl, &c., &c. The gain to-
prescribers in ordering such drugs under their Codex names will
be threefold : first, thej^ will be prescribing a drug of whose nature
and composition they are aware, they will discourage the
introduction and use of quack nostnmis and secret remedies,
and they will in many cases place remedies within the reach of
patients who could not afford to pay the fancy prices at which
many fancy patent drugs are sold.
The Prevention of Senility and a Sanitary Outlook. By
Sir James Crichton-Browne, M.D., LL.D., F.R.S. Pp. 141.
London : Macmillan and Co. Limited. 1905.
This little book contains two addresses, one delivered before
the Preventive Medicine Section of the London Congress of the
Royal Institute of Public Health, the other at a Conference of
the Sanitary Inspectors* Association. Both are pleasant reading,
and are written in the light, picturesque style characteristic of
the author. Without venturing to analyse the factors which
together make the charm of this style, one can at once indicate
two, namely the gift of humour and the judicious use of good
metaphors. As an example of the latter, notice one on page 27.
In speaking of the wear and tear of certain occupations, he in-
stances a Sheffield penknife maker, who delivers 28,000 accurate
strokes with his hammer daily, each stroke requiring a discharge
from the nerve cells of the arm centre. '* Little wonder," he says,
** that these cells, firing 28,000 rounds a day, should sometimes,
be overheated and kick, or should generally suffer erosion."
As might be expected. Sir Crichton-Browne has no specific
for the prevention or postponement of old age. He does not
believe in Metchnikoff's views of the role of phagocytes and the
bacterial flora of the large intestine in delaying or hastening
senility ; neither does he think Dr. AUchin's prophecies are sound.
*' Dr. Allchin," he writes, '' has brought forth the elixir vitce from
limbo, and tricked her out in the fashionable scientific costume of
the hour." Hustling, overeating, insufficient exercise, and
luxurious living generally he considers the main enemies of long
life.
The second of these lectures, on '* The Sanitary Outlook,'"
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consists of carefully-studied statistics, criticisms on Dr. Maudsley*s
and Dr. William Hall's views on consumption and the feeding of
children, a comparison of the death-rate in urban and rural
districts, &c., and the general conclusion that the growth of
healthy suburbs by improved means of travelling, and the en-
couragement of pleasant home life, are the most likely means of
improving the future sanitary condition of England.
Studies in the Bacteriology and Etiology of Oriental Plague*
By E. Klein, M.D., F.R.S. Pp. xv., 301. London : Macmillan
and Co. 1906. — Those who were privileged to hear Dr. Klein's
address to the Bristol Medico-Chirurgical Society on '* Plague,"
in 1 901, will gladly renew acquaintance with the subject in this
volume, in which the whole subject of the etiology and intimate
nature of plague is critically discussed. The bacteriology of the
disease is first dealt with, including a description of the microbes
which simulate in one or another respect the B. Pestis, and the
methods and tests relied upon for discrimination. The important
epidemiological relationships of plague in the rat to plague in man
receive adequate notice ; and it is to be noted that the author
concludes that " there is a distinct failure of evidence that trans-
mission of the- disease is effected by fleas or lice from an infected
animal to a healthy one." On this very important point Dr.
Klein's opinion is not in accord with the results obtained in the
remarkable and complete experiments recorded in the '* Reports
on Plague Investigations in India," issued by the Advisory Com-
mittee appointed by the Secretary of State for India, the Royal
Society, and the Lister Institute, and printed in the September
number of the Journal of Hygiene, 1906, which deserves the care-
ful attention of all students of the subject.
Tumours, Innocent and Malignant. By J. Bland Sutton,
F.R.C.S., Surgeon to and Member of the Cancer Investigation
Committee of the Middlesex Hospital, &c. Fourth Edition.
London : Cassell and Co. 1907. — ^This useful handbook still
continues its successful career. Appealing alike to the surgeon
and practitioner, it contains a large number of illustrations, which
more or less convey the idea of the structures described. A con-
siderable portion of the book is devoted to dental problems. The
section on chorion-epithelioma has been brought up to date. It
is evident that much of the text has been rewritten. Perhaps in
the next edition it will be possible to harmonise the terminology
of the surgeon with that of the academic pathologist.
Opuscula selecta Neerlandicorum de arte Medica. Pp. xii., 325.
Amsterdam : F. van Rossen. 1907. — This volume, published
by a committee to commemorate the Jubilee of the " Neder-
landsch Tijdschrift voor Geneeskunde," contains reprints of four
classical discourses, by Erasmus, by Boerhaave, by Gaubius, and
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the researches of Van Leeuwenhoek and Swammerdam. That of
Desiderius Erasmus, dated Louvain, 13th March, 1518, is in praise
of the art of Medicine. It is written in Latin, but an English
translation faces each page. Leeuwenhoek's essay is in the form
of a letter to the Royal Society of London, giving his views on the
circulation of the blood, in 1688, clearly setting forth that the
arteries and veins are continued blood-vessels. The other essays,
written in Dutch, have French or German translations.
Auscultation and Percussion. By Samuel Gee, M.D. Fifth
Edition. Pp. xviii., 325. London : Smith, Elder & Co. 1906.
— ^The fifth edition of this classical work needs no further recom-
mendation than to refer to the popularity which the previous
■editions have acquired. In the preface the author makes mention
of skiagraphy in physical examination of the chest, and gives his
reasons for not including the subject in this latest edition of his
book, while at the same time he acknowledges the great value of
the method. The alterations and additions to the text are very
few, for indeed there was but little for Dr. Gee to modify or add to
in the earlier editions of a work which will always remain to us as
a model of hterary style, combined with scientific accuracy and
historical erudition. *' Sunt clari hodieque et qui olim nomina-
buntur."
First Lines in Midwifery. By G. Ernest Herman, M.B.
Pp. xii., 222. New Edition. London : Cassell & Co., Limited.
1907. — ^The difficulty in a small book which deals with a large
subject is to get the proper balance in what is necessarily an
abstract. This is most successfully accomplished in this case, and,
considering its small size, a remarkable r^sumd has been compiled.
The illustrations are very numerous, and carefully chosen, and the
text is written in a clear and simple style that is easy to follow.
It would be well, to recommend a doll as well as a skull for
learning mechanisms with, especially to beginners. One wonders
also why no mention is made of gentle massage of the breasts in .
helping to empty them for '* caking " or *' painful fulness,^' as it
is such a useful adjunct. The book has been well known and
appreciated for many years, and has already been reprinted and
revised many times. The addition of a chapter on the require-
ments of the Central Midwives Board is a distinct advantage.
Ansssthetics and their Administration. By Frederic W.
Hewitt, M.V.O., M.A., M.D. Third Edition. Pp. xxxiii., 627.
London : Macmillan & Co., Limited. 1907. — ^The third edition
of Dr. Hewitt's well-known work on Ancesthetics and their
Administration, comes at a very opportune moment, seeing how
much work has recently been done on the subject ; and, as might
be expected, this volume contains much new matter, dealing with
such questions as ethyl chloride, surgical shock, acid intoxication,
and the exact dosage of chloroform, and the author's views on
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these points are as welcome as they are fair and clear. We regret,
however, to note the omission of an account of local and of spinal
analgesia. In the chapter devoted to the ** Physiology of Anaes-
thesia," special reference is made to the interesting researches
of Hamilton Wright on the inimical effects of ether and chloroform
upon the nerve cells of the brain and spinal cord ; and a note has
been made of the work of Kemp, Maunsell, and S. and H. Pringle,
which shows that prolonged ether administration tends to seri-
ously affect the organism. Under ** Physiology of Chloroform
Anaesthesia '* has been added a concise description of the exact
percentage apparatus of Waller, Dubois, and Collingwood ; also a
resume of the researches by Embley and pthers, showing the
•depressing effect of lowered blood pressure upon the function of
respiration ; and the author points out that, according to Snow,
primary cardiac paralysis from chloroform poisoning only occurs
with high percentages of the drug, and that in the absence of such
concentration the heart only fails secondarily to respiratory
depression. The whole of Part II., dealing with the preparation
of the patient, the selection of the anaesthetic, and the method and
-circumstances of administration has been very carefully rewritten,
and much practical matter has been added. On page 375 the
author discusses the Vernon Harcourt apparatus. On the whole,
the volume combines the completeness of a reference book with
the conciseness of a student's manual, and the fairness and
impartiality of a standard work. And the preface should not be
overlooked, as it is in itself an able appeal and an eloquent
effusion.
Anaesthetics, their Uses and Administration. By Dudley
WiLMOT Buxton, M.D., B.S. Fourth Edition. Pp. viii., 415.
London : H. K. Lewis. 1907. — In re-editing his manual on
anaesthetics. Dr. Dudley Buxton has succeeded in introducing
much that is new without in any way interfering with the com-
pactness and clearness which characterised the previous editions.
Not only is the dosimetric method of administering chloroform
•described, but ethyl chloride is dealt with in full, and room has
been found for a good account of local and spinal analgesia. As
regards the fatalities under ethyl chloride, the author says that
it is probable that this drug ''is less safe than nitrous oxide, and
must be placed between ether and chloroform in normal patients,
but before ether when lung and kidney complications exist." On
summing up the arguments in favour of spinal analgesia. Dr.
Buxton says " those who have employed this method fail to show
that it is safer than chloroform, or more free from unpleasant
sequelae,'* and he quotes Hare's opinion " that it is only applicable
to cases for which general anaesthesia is an impossibility." Under
local analgesia reference is made to the faintness and respiratory
•difficulty which are produced by excessive doses of adrenalin
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chloride, and for injection a solution of i in 200,000 is recom-
mended. The present edition is very welcome, and will doubtless
be even more popular than its predecessors.
Guide to Anesthetics. By Thomas D. Luke, M.B. Third
Edition. Pp. xvi., 136. Edinburgh : William Green & Sons. —
This excellent little book has in four years reached its third edition,
which fact in itself bears testimony as to its merits. As the
present edition appears within two years of the previous one it
has naturally been found unnecessary to make many changes in
the text. We are of opinion that the section dealing with local
anaesthesia should be more fully written up. There is every
reason to think that Dr. Luke will soon be called on for the fourth
edition.
Golden Rules of Medical Evidence. By Stanley B. Atkinson,
M.A., M.B. Pp. 63. Bristol : John Wright & Co.— This little
book is by one who combines in himself the qualifications of doctor
and barrister. The subject lends itself well to summary in this
way, and the book is really valuable. The hints are most ex-
cellent and practical, and should save many a mistake. It is
just the thing to refer to when concerned in a medico-legal case,
as it does not take ten minutes to look right through the book.
A few of the aphorisms may be quoted as specimens : '* Preg-
nancy must not be asserted until quickening has been felt, or the
foetal parts are palpable. '* " The body of the coroner's officer is-
always available for ocular demonstrations to the jury of the sites
of injuries." " An early ' I don't know ' is better than a late-
* I did not know.' " ** If you attend a court after being sub-
poenaed, the fee is due even should no e\adence be called."
Pulmonary Consumption. By Arthur Latham, M.D. Pp. vii. ,
259. London : Bailliere, Tindall & Cox. 1907. — A third edition
of this work on the diagnosis and modern treatment of pulmonary
consumption, with special reference to the early recognition and
the permanent arrest of the disease calls for little comment.
New sections have been inserted on such subjects as the value
of the opsonic index in diagnosis and treatment, the use of Koch's
new tuberculin in treatment, and Dr. Paterson's interesting
observations on the value of manual labour at Frimley Sanatorium.
The book is one which should be studied by all who are interested
in questions relating to the sanatorium treatment of phthisis.
Catalogue of the Pathological Museum of the Manchester
University. By J. Lorrain Smith, M.A., M.D. Manchester:
Sherratt and Hughes, at the University Press. — ^To the Museum
curator this catalogue must prove of good service. It is arranged
upon the decimal system of classification, which provides the
means of describing the anatomical and pathological appearances-
by means of decimals. In addition, however, the specimens are
fully described. As this catalogue represents the contents of the
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Manchester Pathological Museum, it must be conceded that the
Northern University has an excellent collection of specimens
illustrating morbid lesions. We thoroughly recommend the
perusal of the catalogue to those who are arranging museums or
undertaking original research. It is almost unnecessary to add
that Lorrain Smith's part in the work represents the high standard
of excellence which we are accustomed to expect from him.
Aids to the Treatment of Diseases of Children. By John
McCaw, M.D., R.U.I., L.R.C.P. Edin. Third Edition. Pp. xiii.,
3S3. London : Bailliere, Tindall & Cox. 1907. — We are never
quite sure whether we like least small books on big subjects, or
big books on small subjects. The present volume may perhaps
be included in the former class, as, although the title limits its
scope to *' Treatment," this cannot be considered to any advan-
tage apart from diagnosis, symtomatology, pathology, &c. ; in fact,
on turning over the pages we find the ordinary arrangement is
adapted, and each disease is considered under the above headings,
treatment occupying no more than its usual share of the available
space. Moreover, sufficient care has not been taken to exclude
conditions which are dealt with in the ordinary text-books on
medicine, and are not peculiar to or even common in childhood.
Thus hydatid of the liver, cerebral tumour, Raynaud's disease,
and amyloid disease are described in a manner too short to be of
much value to the student. With the main part of the book,
except for its brevity, we have little fault to find ; there is a very
succinct account of the principles of infant feeding and the digestive
disturbances of young children, a section on the specific fevers,
which does not differ much from that in most text-books of
medicine, and a short account of circulatory and respiratory
diseases. A propos of the latter, we are surprised to note that the
author recommends aspiration in the treatment of empyema as a
first resort. Other sections on blood, general and nervous diseases
complete the book. There are, we suppose, some types of mind
who are really *' aided " by little books like this, and for them this
one is sufficiently reliable. Judgment and experience, the
essentials in the treatment of children's diseases, cannot be
acquired from any book, but may certainly be materially assisted
by some of the larger monographs on the subject. The book is
well got up and printed, and has an adequate index.
St. Bartholomew's Hospital Reports. Vol. XLII London :
Smith, Elder & Co. 1907. — There are many valuable and in-
teresting papers in this volume of the reports. We may refer to
a few which have specially interested us, but there are many others
of equal importance, and amongst these we may mention a very
exhaustive one by Dr. Finlay Alexander on " Hypertrophic
Pulmonary Osteo- Arthropathy," with several good skiagraphic
plates. Altogether readers of this volume, whether their interests
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are medical or surgical, will find much to interest them. Dr.
Herbert Williamson records two cases of large, partly solid and
partly cystic, embryomata, one occurring in a girl of 16, and
the other in a young man of 23, which on microscopic examina^
tion showed various elements of complex tissue, such as bone,
cartilage, nervous tissue, and tissue resembling intestinal mucous
membrane, as well as tissue quite like that of ordinary sarcoma
and carcinoma. He refers to other cases of these ** embryomata "
published during recent years, and describes their character and
symptoms, and relation to other forms of growth. His communi-
cation is one of considerable value. Mr. Elmslie contributes a
paper on " Late Rickets : or the Continuation of Early Rickets to-
an unusually late age." He regards the changes in the epiphyses
at the wrist as the essential condition in rickets, and refuses to
recognise a case of genu valgum, even with marked bony defor-
mity, occurring over ten years of age, as late rickets at all. We
fail to see why we should thus limit the term *' late rickets " to
cases with epiphyseal enlargement only. Of what nature, we
should be inclined to ask, does he consider the disease which,
manifests itself as marked deformity in the bones of the limbs in
young persons from ten to twenty years of age ? He gives us in
his paper a table of cases of late rickets accompanied by epiphyseal
enlargement. Mr. Faulder, who has been studying bronchoscopy
at the clinic of Prof. Killian, of Freiburg, writes an interesting-
account of its use and the indications for it. The great difficulty
he admits is to get the needful experience. He says, " Evidently
the best way is to practise on a living subject, if such be found."
We hardly think such could or should be found for the manipula-
tive practise of the method which involves passing the instrument
through the larynx into the trachae. Its value in practised hands
seems to be great in detecting foreign bodies in the bronchus, and
he tells us of a case in which a stricture of the bronchus was seen
and dilated with its aid.
Diseases of Women. By George Ernest Herman, M.B.
Third Edition. Pp xvi., 900. London : Cassell & Company
Limited. 1907. — ^The present edition of this well-known work has
been thoroughly revised and brought up to date. The plan of the
book is substantially the same as in previous editions. Chapters
IL — V. are devoted to a consideration of the principal symptoms
of which gynaecological patients complain ; and although this
arrangement has its drawbacks, it is one which should prove very
useful to students and practitioners. With regard to the treat-
ment of uterine displacements, the author considers ventrofixa-
tion the most satisfactory operation for prolapse, and that of
vaginal fixation for retroflexion. For intractable cases of chronic
salpingo-oophoritis, removal of the uterus and appendages through
the vagina is recommended ; we think, however,* that in most
cases the abdominal operation would be the easier and safer.
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The chapters on malignant disease of the uterus have been en-
larged, and a fuller description of its pathology added. There is
also a good account of chorio-epithelioma. For cases of fibro-
myoma of the uterus requiring operation the author recommends
abdominal hysterectomy ; myomectomy he considers has a very
limited field of usefulness, and oophorectomy is obsolete. In
Chapter I. a good account of the pathology of vascular caruncle
is given. Throughout the book special attention is devoted
to the clinical aspects of diseases of women, and the details of
treatment and operative measures are fully described. The
illustrations throughout are numerous and well executed, and the
letterpress is excellent.
Annual Report of the Board of Regents of the Smithsonian
Institution for the year ending June 30th, 1905. Washington :
Government Printing Office. 1906. — ^This is not such a bulky
volume as usual, but the papers which it contains are of the same
absorbing interest that we are accustomed to. The papers dealing
with medical subjects are a paper read before the Indian section
of the Society of Arts in May, 1905, by Dr. Creighton on *' Plague
in India," in which he points out that plague especially affects
villages where fhe inhabitants live in dwellings the walls of which
are made with mud, and that there can be no real cure for the
devastations of the disease without a more civilised kind of
dwelling ; and one on the ** Fight against Yellow Fever," by
A. Dastre, showing the success that has been obtained in stamping
out yellow fever by waging war against the special mosquito
which is the cause of the disease. Another medical paper is.
" Progress in Radiography," by L. Gastine, written in 1905.
Since this date still further progress has been made in this science,
and it is interesting, on looking over a paper written only two
years since, to see how X-ray methods continue to be improved.
A very curious paper to read at the present day is a " History of
Photography," which consists of extracts from a Manual of
Photography by Robert Hunt, published in 1854, and is devoted
to giving an account of Sir John HerschelFs researches into the
effect of light on substances other than silver salts — such as the
cyanides — and his efforts to get a workable photographic process
from the same. Papers on the '' Genesis of the Diamond," '* Gold
in Science and in Industry," and *' Liberia " may be picked out
as well worth reading ; but perhaps the paper of all others which
appealed to us was the paper read before the Royal Geographical
Society in February, 1905, by Sir Frank Younghusband on the
'* Geographical Results of the Tibet Mission." The enthusiastic
way he describes the scenery passed through, the way the members^
of the expedition bore their privations, and the successful accom-
plishment of the expedition, makes one of the most refreshing,
bits of reading that we have come across for a long time.
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EMtorial 1Rotc6.
A SPECi.\L meeting of the Governors of
Bristol this institution was held in the board-room
Royal on December 5th, to consider changes in
Infirmary. the rule 36, when, as the outcome of the
recent controversy and in accordance with
the agreement arrived at previously between the Committee and
the Faculty, the following rule was put to the meeting and
carried : —
" No member of the Honorary Staff shall hold any
Union or Club appointment. No member of the full
Staff, or of the Assistant Staff, shall hold any other
General Hospital appointment or more than one special
Hospital appointment, but this rule shall not preclude
members of the Honorary Staff accepting purely con-
sulting and not active appointments at another hospital.
That the full Physicians shall limit their practice to
medical work. That the full Surgeons shall limit their
practice to surgical work. That each of the Specialists
shall limit his practice to his speciality,'*
thereby annulling the rule proposed and carried at the last Board
meeting, and to which the Medical Faculty could not give its
consent.
« « « « «
Dr. W. Hale White, in his address
Food-fads in Medicine, delivered at the Annual
and Faddists. Meeting of the British Medical Association
at Exeter, pleading for accuracy of thought
in medicine, and speaking on the habit of using the term irregular
gout as a cloak for pathological ignorance, remarked that '* the
symptoms of irregular gout were commonly ascribed to an excess
of uric acid or bodies allied to it in the blood. Some do this
without knowing the amount of uric acid present in the blood
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EDITORIAL NOTES. 369
•^f a healthy person, without drawing any distinctions between
-endogenous and exogenous uric acid, without any attempt to
estimate the uric acid in the patient's blood, without any
experimental evidence that the injection of uric acid into the blood
produces the symptoms in question, and without any thought of
the fact that in some forms of leukaemia there is an excess of
uric acid in the blood without the symptoms supposed to indicate
suppressed gout. This doctrine has become so widespread, thai
even the public tell us that their symptoms are caused by an
excess of acid. Having assumed, not proved, that the symptoms
the patient has are due to irregular gout, and having assumed,
not proved, that this is due to an excess of uric acid, the next
assiunption made is that certain foods cause an excess of uric
acid ; some say carbohydrates, some say fats, some say proteids,
and it would be quite easy for a patient to consult three doctors
in turn, and if he followed all, his diet would be water and nothing
•else. He who believes proteids harmful is the most artistic,
for he has an eye to colour, and may, as a concession, allow white
meat although he prohibits red. Where, on earth is the
justification for this ? Are there any experiments showing that
steak leads to more uric acid in the blood than chicken ? Have
a hundred cases of so-called irregular gout been published and.
contrasted with another hundred similar in their treatment,
except that in one series red meat was replaced by an equal
amount of white ? Surely you will agree with me that all this
is not a credit to us as members of a scientific profession. The
simple fact that although gout has become much less common
the consumption of meat has enormously increased, ought alone
to make those who forbid proteids pause. The imagination of
some has carried them still further. The fact that both gout
and chronic osteo-arthritis are long-lasting diseases of joints has
led them to think that as sufferers from one should be dieted,
so those afflicted with the other ; hence we find patients who have
■chronic osteo-arthritis forbidden various articles of food, some-
times, for example, sugar. Looked at calmly this is extraordinary,
for there is not an atom of evidence that any particular article
of food influences chronic osteo-arthritis. Have we in some of
TOL. XXV. No. 98. Digitized by Google
370 EDITORIAL NOTES.
our statements about the harmfulness of particular foods advanced
beyond Ibu Haukal, who in about a.d. 950, describing the
inhabitants of Palermo, said, '* Their evil habit of eating raw
onions in excess ; for there is not a person among them, high or
low, who does not eat them in his house daily, both in the morning
andv evening. This is what has ruined their intelligence, and
affected their brains, and degraded their senses, and distracted
their faculties, and crushed their spirits, and spoiled their com-
plexions, and so altogether changed their temperament that
everything, or almost everything, appears to them quite different
from what it is. '* I strongly suspect that in those days onions were
a cause of irregular gout.
The literary output on the subject of foods and food-fads has
of late been enormous. The older views of Banting, the more
modern ones of Fletching, the grape-nuts of Bernard Shaw, the
apples of Haddow, the various vegetable fancies of Eustace
Miles, the cheese diet of Dr. Haig, the use of Bulgarian sour
milk, and that of a crowd of patent foods and drinks of
various kinds, lead to the natural conclusion that a diet
grounded on common sense is, perhaps, after all the best. Some
are afraid of meat because of its toxins, and of broths because
.of their purin and waste products ; others fear that a vegetable
diet may end in gastric dilatation, and that sadads may harbour
uncooked microzoa and bacteria ; milk and butter must be
dangerous inasmuch as they harbour the germs of tubercle ; even
biead may charge the blood with acids, whilst water may contain
the germs of typhoid, and alcohol is a concentrated poison:
hence it may be assumed that the only reasonable course is to
eat, as appetite prompts, those viands which have beeji found by
the experience of centuries to be harrnless, and that neither the
use of meat, soup, wine, condiments, fruits, vegetables, or coifee
will be likely to shorten our days, although the abuse of some of
them may.
It has been pointed out by Pawlow that we cannot Hve on
chemical formulae or on calories, and Chittenden maintains that
the dietetic customs and habits of mankind are not much to the
point, inasmuch as instinct and craving are not wise guides. What
Digitized by VjOOQIC
EDITORIAL NOTES. 37I
has been called the " cabbage inspired '' writings of the vegetarians
are still less to the point, but direct physiological experiment
should be the only scientific guide to an '* ideal diet.'* Chittenden
pleads that over-feeding is the predominant dietetic sin ; his
newer experiments on dogs on the effects of a low proteid dietary
confirm his former views that the commonly accepted " normal "
and " standard '* diets contain an excessive amount of proteid,
and he has shown by observations on men of the Army Hospital
Corps, and more recently again on university athletes, that
the body weight and nitrogen equilibrium can be maintained
on an amount of proteid food far below the usual dietary
standards, i
Far more important than the regulation of the quality of the
food appears to be the important questions relating to the quan-
tity of the same. These are discussed at considerable length by
Van Noorden2 in chapters on under-feeding and over-feeding.
The general conclusion appears to be that it is impossible to draw
up fixed, rigid rules for the individual ; the personal equation is
the all -important question, hence there is much excuse for the
numerous vagaries in diet now in vogue, and much scope still
remains to the manufacturing chemist for the unlimited increase
of eccentricities in food and drink.
The importance of the personal element in dietetics is well
illustrated by Dr. Leonard G. Guthrie. 3 He writes as
follows : —
" The diet suitable for neurotic children is indeed always
a matter of perplexity — no fixed rules for all are possible. Some
abhor milk in any form, and would live on meat and pickles
only ; to others, meat and fat in almost any shape are
abominable ; some can only relish bread and butter, sweets and
jam ; some can hardly be induced to touch fresh vegetables or
fruit, others would live on nothing else ; some regard with
suspicion the slightest variation and innovation in their diet,
others will not eat the same food twice.'* He further adds that
1 The Nutrition of Man. Chittenden. Heinemann, 1907.
2 Metabolism. Translated by Walker Hall. Heinemann, 1907.
3 Functional Nervous Disorders in Childhood. Oxford University-
Press, 1907, p. 25.
Digitized by VjOOQIC
372 EDITORIAL NOTES.
^' Qur tastes and distastes with regard to food are generally
formed in early life, and what we do not like is almost certain to
disagree with us.** We all realise how difficult the problems of
diet in sickness become w^hen the patient has abhorred' milk in
early life, and will have none of it afterwards.
The second annual report of this Institution
Winsley has been before us for some months. The
Sanatorium. medical profession generally is fully alive
to the value of the work done in an
Institution which ha^ now shown itself to be a necessity, and to
be an indispensable auxiliary to the National Association for the
Prevention of Consumption. We think, however, that the public
has not yet fully realised what good work is being done for the
three Counties of Gloucester, Somerset and Wilts, and the City
and County of Bristol. The Sanatorium is saving and prolonging
many valuable lives, and is doing a great educational work. , It
is not, however, sufficiently known that whilst its finances
remain in the unsatisfactory state which still continues it has
been arranged by the Board of Governors that " In case any
maintained bed shall not have been actually allocated to a local
authority, public body, firm, group of persons, or private donor,
who shall have agreed to maintain the same, the committee of
management shall be at liberty to admit patients to such bed at
the following charges : To persons resident within the Counties
of Somerset, Gloucester and Wilts, and the City and County of
Bristol, -£1 15s. per week ; to persons not so resident, £2 los. per
week.'* During the past year many paying patients have been
admitted under this rule, and it is of great assistance to the funds
to have these beds fully occupied. Medical men are asked to
remember that there is commonly no difficulty in securing
admission to any patient on this basis.
We are glad to take this opportunity to welcome the arrival
of the newly-appointed medical officer, Dr. A. Lewthwaite, who
comes from Dr. Otto Walther's Sanatorium in the Badischer
Schwarzwald.
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Google
.: EDITORIAL >[OTES. 373
We wish to direct especial attention to a
An Imperial review of the British Pharmaceutical Codex
Dispensatory. for the use of medical practitioners and
pharmacists which will be found on page 358.
This Codex has been published by the authority of the
Council of the Pharmaceutical Society of Great Britain, and
although it has not quite the authority 0/ the British
Pharmacopoeia it is likely to be a far more useful work, Every
medical man should possess it, and it should be a constant
companion both to prescriber and dispenser. We are indebted
to Mr. A. L. Taylor, of the Bristol Royal Infirmary, for the
excellent summary of a book which must make a great difference
in the work of the pharmaceutical dispenser throughout the world.
* ♦ ♦ ♦ ♦ .
A STRIKING, if unintentional, testimony to
,. " Codex ** Review, the value of the new Codex is provided by
a httle red pamphlet, received apparently
by all the members of the medical profession in Bristol, and
presumably other places, entitled " A Curious Codex." The
noble and disinterested zeal with which the author expresses
his righteous indignation at the omission of the mention of
" Gingament " will surely be recognised by all prescribers of
"Oids."
Two salient facts stand out in happy contrast to the mass
of puerility and diluted sarcasm provided by the writer. One,
already dealt with in the review of the Codex in this number,
the need for some distinguishing mark of the B.P. article as
compared with B.P.C. The other — the writer's own statement,
born doubtless of inward conviction — that his pamphlet is too
long.
* * * * ♦
The Right Hon. Lewis Fry again presided'
University College, at the annual distribution of prizes to the
Bristol, Faculty of students of the medical department of the
Medicine. CoUegie at the commencement of the
medical session in October, when Professor
Francis Gotch, M.A., D.Sc, F.R.S., gave a highly stimulating
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374 NOTES ON PREPARATIONS FOR THE SICK.
address on the question of University extension, and asked the
question : " When will Bristol do what Liverpool has done, and
attain its educational manhood." Prof. Gotch, as a Bristolian, is
anxious for the reputation of the city. It was his hope and his
firm beUef that he might very shortly have the great pleasure of
rejoicing with his fellow-BristoUans over the reahsation of the
long-expected University scheme, for when once started on a wide
basis, it would astonish them by its vitality and free growth, and
would become the prjde of those who established and supported it.
Another noteworthy address given recently is that of Prof.
Francis Francis on " The Nitrogen of the Atmosphere/' par-
ticularly in relation to food supply.
The annual dinner was presided over by an old and distin-
guished student of the College, Mr. J. H. Parsons, F.R.C.S.,who
was supported by Prof. Francis Gotch as the guest of the evening.
Prof. Walker Hall, in responding to the toast of the Bristol
Medical School, remarked that this Faculty is a soiurce of strength
to the city and county, that it is an important factor in the every-
day Ufe of the community, and that it is doing good work, which
will at one time or another benefit the individual citizen.
Prof. Gotch*s missionary- effort on behalf of the University
scheme should do much to stimulate the local influences which are
working steadily in that direction.
IRotes on preparations for tbe Sicft.
Kuhn's Suction Mask. — Robohat Company, 8 Harp Lane,
London, E.G. — For the congestive treatment of pulmonary
tuberculosis and asthma, in accordagnce with Prof. Bier's system
^i artificial hyperaemia. The mask^ made of celluloid, the
Igputh and nose portions being separaR^hambers. When applied
to the face by means of the elastic band (which should be fastened
round the neck under the ears), both nose and mouth are com-
pletely shut in. The air tube should be always well inflated, a
tight constriction being placed around the small rubber tube after
blowing up. A trial may then be made with, the sUding valve in
the nose portion completely closed, w|^en reispiration will be found
Digitized by VjOOQIC
NOTES ON PREPARATIONS FOR THE SICK. 375
to be SO much impeded as to become impossible. As a general
rule, breathing should take place only through the nose, though in
case of impediment arising from cold or other cause, air may be
made to enter the mouth by opening the sliding valve in the cross
partition. Expiration occurs unhindered through the circular
valve provided for the purpose in both portions of the apparatus,
and, with practice, can be made to take place quite freely through
the mouth even with the valve aperture somewhat diminished.
The aim of the use of the mask is, by providing a resistance to the
intake of air into the lungs, to bring about an increased negative
pressure in the thorax and thereby suction of blood into the lungs.
The greater the resistance, therefore, and the longer it is con-
tinued, the greater becomes the amount of blood flowing into the
lungs. It should not, however, be so great or so long continued
as to bring on unpleasant by-e£fcts, such as headache or other
discomfort. It is quite possible that during the first few days of
use there may be some singing in the ears, in which case it is
recommended that the mouth be closed, the nose held, and the
cheeks inflated, when it will be found that air drawn out of the
middle ear while wearing the mask is replaced through the
Eustachian tubes. Another simple remedy is to make a few
purposeful swallowing movements. This symptom is not of
frequent occurrence, and in any case disappears after a few days.
Inspiration against resistance by means of this method should be
an active agent in the treatment of anaemic or tuberculous subjects.
An increase in the munber of red blood corpuscles is brought
about, and an increased hyperaemia should have a beneficial in-
fluence upon the upper parts of the lungs which are most prone
to tuberculosis. Good results have been obtained by Prof, von
Leyden at the Berlin Charity.
Formidine : Methylen Disalicylic Acid Iodide. — Parke,
Davis & Co., London. — Formidine is an internad and external
antiseptic and a substitute for iodoform. It is a true chemical
compound, a condensation product of iodine, formic aldehyde, and
salicylic acid, having the formula CifHio^6l2- It may be called
an iodised derivative of salicylic acid and formic aldehyde, ex-
hibiting none of the physical characteristics nor responding to any
of the chemical tests for its constituent bodies until decomposed.
Formidine is a reddish-yellow powder, tasteless, and having a
slight but not disagreeable odour suggestive of iodine ; it contains
about 47 per cent, of this element. It is perfectly stable in the
■dry state. When heated, iodine is liberated, the substance melts,
then chars, and is finally consumed without leaving any ash. It
is insoluble in water, dilute acids, alcohol, and most other ordinary
solvents, and does not decompose with glycerin. \Vhen brought
into contact with alkaline organic secretions it slowly dissolves
and develops the characteristics of its constituents, iodine.
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376 NOTES ON PREPARATIONS FOR THE SICK.
salicylic acid, and formic aldehyde. It is supplied in five grain?
capsules for internal administration, and in this form it appears-
f o be one of the best of intestinal antiseptics.
Egmol. — ^Parke, Davis & Co., London. — ^This preparation:
contains 40 per cent, of finest olive oil emulsified with fresh eggs
and flavoured with best French brandy. It is a nutritious and
stimulating food, which may be prescribed with excellent effect iiL
wasting diseases. For those patients who cannot tolerate cod
liver oil, egmol forms an excellent substitute ; indeed, experi-
ments carried out by Cunningham (vide Journal of Physiology,.
xxiii. 209) seem to show that owing to more perfect assimilation,
olive oil may be ranked above cod liver oil as a flesh former and
heat producer. Egmol is a perfect and stable emulsion, and in.
every way an excellent example of good pharmacy.
Petroleum Emulsion.— Parke, Davis & Co... London.— In
spite of its slight utility, there has arisen a demand for an emulsion,
of petroleum. Much of the liquid paraffin of commerce is un-
deriirable for medicinal use, but in the P. D. & Co. petroleum
emulsion a pure fluid hydrocarbon is used, which is wholly free
from acid traces and from the sulphur compoimds often present
in imperfectly refined liquid paraffin, and with it are associated
suitable amounts of the hypophosphites of calcium and sodium.
Adrenalin and Ghloretone Ointment. — Parke, Davis & Co.,
London. — ^This addition to the various modes of applying adrena-
lin contains one part of that drug with fifty parts of chloretone in.
each 1,000 parts, and by thus combining the constringent, analgesic
and antiseptic powers of its constituents forms a most effective
remedy in all indolent inflammations, in hemorrhoids, pruritus,
ani, pruritus vulvae, eczema, chronic congestions of the nose and
ear, &c. In ophthalmic work it is useful in simple or purulent
catarrhal inflammations. It is supplied in collapsible tubes with,
elongated tips, which facihtate nasad or rectal medication.
Cholelilh Pill (Pilula Cholelithica).— Parke, Davis & Co.;
Tlondon. — ^This chocolate-coated pill is a combination of oleate
and silicylate of sodium with phenolphthalein and menthol. It
is a new combination of drugs, which appears to have marked,
power to increase the amount of hepatic secretion, and to promote
a due proportion of biliary acid salts wherewith to dissolve
gall concretions, or at least so to diminish their size that they
may be expelled naturally.
Black Wash Tablets.— Parke, Davis & Co., London.— The-
provision of the chemical constituents of lotio hydrarg. nig. B.P..
Digitized by VjOOQIC
NOTES ON PREPARATIONS FOR THE SICK. 377
in accurate proportions needing only to be treated as directed on
the label, will be found a great convenience, particularly by
medical officers to expeditions, to whom lime water may be a
troublesome, if not unattainable, item.
'' Tabloid '' Capsule Calcium lodo-Rieinoleate, gr. 3
(0.194 gm.). — Burroughs, Wellcome & Co., London. — Calcium
iodo-ricinoleate is a new salt containing a large proportion of
iodine, which combines the therapeutic value of calcium and of
the iodides. It is tasteless and odourless, and is not affected
by the gastric juice. It produces no digestive disturbance, and
is well tolerated by patients who cannot take potassium or sodium
iodide.
Calcium iodo-ricinoleate possesses in a marked degree the
valuable action of its components, and in syphilitic cases the results
.obtained compare favourably with those of treatment by the
iodides. It has proved very successful in condylomata and other
specific manifestations, whilst in stubborn cases of ulcers^
including rodent ulcer, which resisted other treatment — it has
been reported to produce a healthy granulating surface. Various
affections of lymphatic glands and of the thyroid have been
favourably influenced by the administration.
One to three may be swallowed with water three or four time$
daily after food.
" Phytin " Preparations. — Society of Chemical Industry^
Basle. London Agency, Harp Lane, E.C. — " Phytin " is stated
to be the organic phosphorus-reserve material of green plants,
and has been extracted from numerous seeds such as peas,
haricot beans, and sunflower seeds.
It is a white powder, almost tasteless, and not very soluble
in water.
Examination showed it to contain organically-combined
phosphorus in large quantity.
It is supplied in capsules in the Hquid form, and in
combination with quinine.
For children it is prepared in combination with sugar of milk
under the name of " Fortessan."
No doubt the various ".Phytin'' preparations will prove
valuable adjuncts to the older phosphorus-containing organic
compounds used in medicinal dietetics.
Theinhardt's Food for Infants. — ^Theixhardt's Food Com-
pany, London, E.C. — ^This food has gained considerable popularity
during recent years, and is no doubt one of the best on the
market.
The makers claim it to be " The Ideal Food for Infants,"
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378 NOTES ON PREPARATIONS FOR THE SICK
this being partly based on a table giving the analyses of various
proprietary foods.
We may point out that chemical analysis is not by any means
the chief criterion of '* food value/' and many of the foods which
are compared with " Theinhardt's *' have proved themselves to
be of great value in the diet of infants and invalids. We consider
that any preparation should be judged on its own merits, and
not on the doubtful demerits of others.
The analyses of various foods, compiled from Hutchison's
and Konig's works on the subject, give very interesting results,
but the table is too lengthy to reproduce. It shows that the
Infantina food (Theinhardt's Soluble Infants' Food) contains a
very high percentage of nitrogenous and fatty matters, and that
the Hygiama is even richer in nutritive matter of the highest
value.
We are informed that these foods are in constant use at the
Milk Depots of Berlin and Charlottenburg. The Infantina is
intended for infants from birth up to two years of age, and the
Hygiama is for older children and adults.
They are excellent foods, worthy of all commendation. The
Hygiama differs from the other food in that it is flavoured with
cocoa, and may be taken either in solid form, or as a substitute
for t^a or coffee : when so used it forms a very palatable and
nutritious beverage.
" Manhu " Diabetic Foods. — Manhu Food Company, .Liver-
pool. — Under the above name several preparations are introduced
for the use of diabetic subjects.
The firm claim that they have " changed " the starch without
eliminating it, thus rendering it perfectly safe for diabetic
patients.
This statement admits of criticism, for it is doubtful whether
a physical or chemical change is referred to.
On several occasions we have chemically and microscopically
examined several *' Manhu " preparations, and found abundant
evidence of the presence of starch, which gives the usual
re-actions characteristic of this substance. Under these circum-
stances it is hard to understand the great superiority claimed
for such preparations, as physicians can only condemn " diabetic "
foods which actually contain starch grains in abundance.
We are of opinion that such foods as this for the diabetic
are very misleading and dangerous. They are given to patients
to whom starchy foods are forbidden, and the result is
sometimes disastrous.
" Miol.*' — MiOL Manufacturing Company, 66 Southwark
BriOge Road, London, S.E. — Within the last few years numerous
Digitized by VjOOQIC
LIBRARY. 379
compounds, with malt extract as the chief ingredient, have been
manufactured.
" Miol *' appears to be one of the latest of these, a distinctive
feature being that it contains, among other ingredients, the
finest olive oil.
It is recommended as a valuable food in consumption and
other diseases where cod liver oil is usually prescribed.
" Miol '* is not unpleasant to take, the taste of the olive oil
being partially covered by the malt ; but we think it somewhat
doubtful whether olive oil approaches cod liver oil for the cases
in which the latter can be absorbed and assimilated.
" Miol '* may prove of service in those cases where prepara-
tions of cod liver. oil cannot be administered or digested.
XEbe Xibxavs of tbe
Bristol /IDe&ico*CbirutQical Society?*
The following donations have been received since the publication
of the List in September :
November ^oth, 1907.
The Chicago Pathological Society (i) . . . . i volume.
L. M. Griffiths (2)
Dr. A. B. Judson (3)
The Middlesex Hospital (4) . .
The Surgeon-General, United States Army (5)
7 volumes.
I volume.
•I
I
SIXTY-SIXTH LIST OF BOOKS.
The titles of books mentioned in previous lists are not repeated.
The figures in brackets refer to the figures after the names of the donors
and show by whom the volumes are presented. The books to which no
such figures are attached have either been bought from the Library Fund, or
received through the Journal.
Allbutt and H. D. Rolleston, T. C. [Eds.] A System of Medicine
Vol. III. 1907
Berdoe, M Essay on the Pudendagra (2) 1771
Bigg, G. S Cancer 1907
Bourcart et P. Cautru, M. Le Ventre. Pars II 1908
British Pharmaceutical Codex, The 1907
Bunge, G. V. .. Text-Book of Organic Chemistry. (Tr. by
R. H. A. Plimmer) '. 1907
'Campbell, H. .. Aids to Pathology 1908
Catalogue (Index) of the Ltbrarv of the Sureeon-GeneraV s Office,
United States Army. 2nd Ser., Vol. XII. (5) 1907
•Cantru, M. Bourcart et P. Le Ventre. Pars II 1908
[Cecil] The Stud Farm (2) New Ed. 1S76
<lolller, R. ' Hutchison and H. S. TEds.] An Index of Treatment 1907
Digitized by VjOOQIC
380 LIBRARY.
Corner and H. J. Plnehes, E. M. The Operations of General
Practice 1907
Crowe, H. W. . . Consumption : Home Treatment and Rules
for Living r2nd Ed.] 1907
Cunningham. D. J. Manual of Practical Anatomy. 2 vols.
4th Ed. 1907
Dampier-Bennett, A. G. Physical Methods in the Treatment of
Heart Disease 1907
Dore, M. Morris and S. E. Light and X-ray Treatment of Skin
Diseases 1907
Encyclopedia and Dictionary of Medicine and Surgerv. Green's
Vols, v., VI.^ [1907]
Esmarch, F First Aid to the Injured. (Tr. by H.R.H.
Princess Christian; . . . . 7th Ed. 1907
Fernie, W. T. . . Precious Stones {Curative) 1907
Goodall, G. H. Savage and E. Insanity and Allied Neuroses
New [srdj Ed. 1907
Harman, N. B. Preventable Blindness 1907
Hart, A. H Some Successful Prescriptions 1907
Hughes, E. L. . . Squint and Ocular Paralysis 1907
Hutchison and H. S. Collier, R. ['Ed?>.] An Index of Treat-
ment 1907
Jones, R Mental and Sick Nursing 1907
Judson, A. B. . . Growth and Deformity (3) 1905
Kenwood, L. C. Parkes and H. R. Hygiene and Public Health
3rd Ed. 1907
M'Vail, J. C. . . The Prevention of Infectious Diseases . . 1907
Manson, Sir P. . . Tropical Diseases 4th Ed. 1907
IfficholitSCh, E. Werthelm and T. The Technique of Vagino-
peritoneal Operations. (Tr. by C. Lockyer) 1907
Morris and S. E. Dore, M. I.tcht and X-ray Treatment of Skin
Diseases 1907
Muir and J. Ritchie, R. Manual of Ba teriology. , .. 4th Ed. 1907
Nelson, J The Government of Children (2^ 2nd Ed. I7s6
Newman, D Movable Kidney 1907
Nichols, J. B. . . Diet in Typhoid Fever 1907
Noorden, C. von .. Metabolism and P'.actical Medicine. (Ed. by
I. W. Hair, Vol. Iir. .. 1907
Parkes and H. R. Kenwood, L. C. Hygiene and Pn'olic Health
3rd Ed. 1907
Parsons, J. H. . . Diseases of the Eye 1907
Partridge, W. .. The BarterioloQiral Examination of Disin-
fectants 1907
Paton, D. N, . . Essentials of Human Physiology 3rd Ed. 1907
Pinches, E. M. Corner and H. I. Tfie Operations of General Practice 1907-
Ritchie, R. Muir and J. Manual of Bacteriology . . 4th Ed. 1907
Robson, A. W. M. Cancer of the Stomach 1907
Rolleston, T. C. Allbutt and H. D. [Eds.] A System of Medicine
Vol. III. 1907
Russell, Hon. R. . . The Reduction of Cancer 1907-
Sajous, C. E. de M. The Internal Secretions. Vol. II igor
Digitized by VjOOQIC
LIBRARY. 381
Saundby, R Medical Ethics 2nd Ed. 1907
Savage and E. Goddall, 6« H. Insanity and Allied Neuroses
New [3rd J Ed. 1907
Schrdtter, L. von . . Hygiene of the Luns;. (Tr. by H. W. Armitt) 1907
Stephenson, S. . . Ophthalmia Neonatorum ' 1907
Taylor, S. .. .. On Acute Pneumonia 1907
Treves, Sir P. .. Surgical Applied Anatomy (Revised by
A. Keith) 5th Ed. 1907
Turner, W. A. . . Epilepsy 1907
Werthelm and T. Micholltsch, E. The Technique of Vagino-
peritoneal Operations. (Tr. by C. Lockyer) 1907
Wilson, T. . . Pelvic Inflammations in the Female . . . . 1907
Wynter, W. E. . . Minor Medicine 1907
TRANSACTIONS. REPORTS, JOURNALS, &c.
American Journal of Obstetrics, The Vol. LV. 1907
American Journal of the Medical Sciences, The Vol. CXXXIII. 1907
American Pediatric Society, Transactions of the Vol. XVIII. 1907
Archives of the Middlesex Hospital (4) Vol. XI. 1907
Boston Medical and Surgical Journal, The . . . . Vol. CLVI. 1907
Bristol Health Report for 1906 1907
British Gynaecological Journal, The . . . . Vol. XXII. 1906-07
Chicago Pathological Society, Transactions of the (i) Vol. VI. 1906
Clinical Journal, The Vol. XXX. 1907
Glasgow Medical Journal, The Vol. LXVII. 1907
Henry Phipps Institute, Third Annual Report of the 1907
Hospital, The Vols. XLI., XLII. 1907
Journal of Medical Research, The Vol. XVI. 1907
Journal of Mental Pathology, The Vol. VII. [1907]
Journal of Obstetrics ajid Gynaecology, The.. .. Vol. XI. 1907
Journal of the American Medical Association, The Vol. XLVIII. 1907
Library Association Record, The Vol. VII. 1905
Library World, The Vol. IX. 1906-07
Medical Chronicle, The N.S., Vol. XII. 1906-07
Medical Press and Circular, The [Vol. CXXXIV.] 1907
Medical Record Vol. LXXI. 1907
Odontological Society of Great Britain, Transactions of the
Vol. XXXIX. 1907
Practitioner, The [Vol. LXXVIII.] 1907
Progressive Medicine Vol. III. 1907
Royal Academy of Medicine m Ireland, Transactions of the
Vol. XXV. 1907
Scottish Medical and Surgical Journal, The . . Vol. XX. 1907
Sociedad de Beneficencia de Buenos Aires — Memoria del 1906 . . 1907
Univ. of Penna. Medical Bulletin Vol. XIX. 1907
Digitized by VjOOQIC
MEETINGS OF SOCIETIES.
Iristol /IDeMco-^Cbirurflical Socfetp*
Annual Meeting, October gth. 1907.
After a vote of thanks to the retiring President, Mr. James
Taylor, had been passed, Dr. Waldo took the chair and gave an
introductory address (see p. 289). Later a cordial vote of thanks
was given to Dr. Waldo for his able and interesting address.
The Honorary Secretary, Mr. H. F. Mole, read his annual
report. The balance in hand, on the ordinary account, was
3^120 i8s. yd. The Society had lost two members through death,
viz. Dr. Markham Skerritt and Mr. H. W. Kendall, and nine
members had left the Society owing to removal, &c. Sixteen
new members had been elected.
The Editorial Secretary of the Journal, Mr. James Taylor,
read his annual report.
Mr. Munro Smith read the Library report, which showed that
there were 20,989 volumes in the library, and that 237 periodicals
were regularly received.
The following officers were chosen for the ensuing year :
President-elect — Dr. Michell Clarke ; Hon. Secretary — Dr. J. A.
Nixon ; Members of G^mmittee — Dr. B. M. H. Rogers, Dr. P.
Watson Williams, Mr. C. K. Rudge, Dr. James Swain, Dr
George Parker, and Prof. Walker HaJl ; Members of the Library
Committee — ^Mr. C. K. Rudge, Mr. Munro Smith, and Dr. C. F.
Carey Coombs.
November 13/A, 1907.
Dr. Henry Waldo, President, in the Chair.
Nearly the whole time of the meeting was devoted to the
consideration of a special report of the Library Committee.
Printed copies of this report had been previously posted to the
members of the Society. The various suggestions made by the
Conunittee for the improvement of the libiary were considered
seriatim, and except for some minor alterations were approved.
Dr. Tkmple showed microscopic sections of a pigmented
growth he had removed two years previously from the prepuce
of a boy aged 9. The small tumour had followed an injury.
A distinguished pathologist had examined the sections, and
pronounced the tumour to be a melanotic sarcoma. Such a
growth at the age of nine and in the situation described seemed
unique.
J. Lacy Firth.
J. A. Nixon.
Digitized by VjOOQIC
LOCAL MEDICAL NOTES.
383^
RECEIPT AND BXPEMDITURE ACCOUNT OF THE BRISTOL MBDICO-
CHIRURGICAL SOCIETY, SESSION 1906-7.
Carried forward from
1905-6
Members' Subscriptions,
1906-7 157 10
Interest on Deposit Xotes 3 4
Feb. 17. — Excess on
Dr. A.'s cheque . . 04
147 14 6 I
;f3o8 12 10
60
I
5
o
o
o
5
2
3 10
o
o
o
6
o
1906. £ s. d.
Oct. 22. — Grant to Li-
brary
Stamps
Grant to Librarian . .
Dec. 19. — Cheque Book
Telephone
1907.
Jan. 10. — Grant to Li-
brary
„ 18. — ^Lamp . .
Feb. 6. — ^Stamps . .
May 23. — ^To Porter . .
24. — For use of
lantern
Sept. 12. — For use of
rooms 52 10
,. 17. — Printing .. i 13
Do 3 II
„ 26. — ^To Journal.. 40 5
Sundries .. 10
15 o o
16 3
100
1 5 3
o 15 6
;fl87 14 3
Balance as per deposit
note No. 375 .. .. 120 18 7
;f3o8 12 10.
local flDcMcal IRotea*
University College, Bristol. — ^Examination Results :—
M.B., B.S. Lond. — A. J. M. Wright (Distinguished in Medicine
and Surgery).
W. S. V. Stock, M.B., B.S. Lond., and S. C. Hayman,
M.R.C.S., L.R.C.P., have passed the final examination for the
Fellowship of the Royal College of Surgeons, England.
M.D. Durh.— H. T. S. Aveline, M.R.C.S.
M.R.C.P. Lond. — George Basil Price, M.D. Lond.
Conjoint Board. — Practical Pharmacy: L. C. Watkins-
Baker, T. E. Ashley. Anatomy and Physiology: B. C. Eskell,
T. S. Rippon. Surgery : C. Clarke, P. S. Tomlinson, E. V. Connellan,
Midwifery : E. R. Sircom.
L.S.A. Lond. — Medicine, Section II. : E. V. Connellan.
L.D.S. Lond. — Chemistry: G. Smith. Final Examination:
Cuthbert G. Plumley. v^
Digitized by VjOOQIC
384 LOCAL MEDICAL NOTES.
Bristol Royal Infirmary. — A. Le>\in Sheppard, M.B., B.S.
Durh., has been appointed Senior Resident Officer and House
Surgeon, and A. W. Falconer, M.D. Aberd., House Physician.
Bristol General Hospital. — The following appointments have .
been recently made : — House Physician : C. S. Rivington,
M.R.C.S., L.R.C.P. House Surgeon : J. W. J. Willcox, M.R.C.S.,
L.R.C.P. Casualty House Surgeon : A. E. lies, M.R.C.S., L.R.C.P.
Assistant House Physician : W. Bruce Low, M.B., B.Ch. Edin.
Long Fox Lecture. — ^The next Long Fox Lecture will be
delivered by Dr. Watson Williams, on Thursday, January i6th,
1908, at 4.15 p.m. in the Medical Library, University College,
Bristol. Subject : " Suppurative Disease in the Nose and Ear,
with special reference to newer methods in Diagnosis and Treat-
ment,"
BRISTOL.
Consultations at the Bristol Workhouses. — At a recent
meeting the Bristol Board of Guardians considered a report
of the hospital committee, which contained a recommenda-
tion to appoint a consultant to be availaible in case of
difficulty occurring in the treatment of patients in the In-
firmary wards at either of the two workhouses, or where
the workhouse medical officer would like to have the advan-
tage of a second opinion. In the discussion of the report it
was stated that there were no suitable operating theatres at
the workhouse infirmaries, and that it was the custom to send
patients for operation to the Royal Infirmary.
BATH.
Bath Royal United Hospital.— Thanks to the efforts of the
Mayor of Bath (Mr. S. W. Bush), this institution is now free from
debt. His Worship, at the outset of his mayoralty, announced
that his endeavour would be to free the hospital from its debt of
jr6,i24, and we heartily congratulate him upon his success.
Bath Royal Mineral Water Hospital. — The governors of this
hospital have decided to decrease the number of beds from 155
to 150 from lack of funds, but the Mayor of Bath is making an
effort to secure increased support, so that this retrograde step
shall not be necessary. It is pointed out that of the present
149 in-patients only one belongs to Bath. It is claimed, there-
fore, that the hospital is national in its operations, and justly
appeals for national help.
Winsley Sanatorium.— Alfred Lewthwaite, M.B. Lond., has
been appointed Resident Medical Officer to this institution, vice
E. D. Townroe, resigned.
Digitized by VjOOQIC
INDEX.
(r.) = Review.
Abdominal aoita. Aneurysm of
the — Dr. F. P. Nunneley (r.), 353.
Acetone bodies, The, 59.
Adami, Dr. J. G. — Inflammation
(R.). 355.
American Pediatric Society, Trans-
actions of the (r.), 172
American Surgery in 1906, Glimpses
of— C. H. Whiteford (r.), 264.
Anaemia, Pernicious, 239.
Anaesthetic poisoning, Delayed, 156.
Anaesthetics, Guide to— Dr. T. D.
Luke (r.), 364.
Anaesthetics, their uses and adminis-
tration — Dr. D. W. Buxton (r.),
363 ; Dr. F. W. Hewitt (r.), 362.
Anatomy : Manual of — Dr. A. M.
Buchanan (r.), 251, 354; Text-
book of — Dr. D. J, Cunningham
(R.), 168.
Aneurysm of the abdominal aorta —
Dr. F. P. Nunneley (r.), 353.
Angioma of the liver. Acquired —
Dr. A. L. Sheppard, 46.
An Imperial Dispensatory : The
British Pharmaceutical Codex (r),
358-
Antenatal pathology and hygiene :
the embryo — Dr. J. W. Ballan-
tyne (r.), 254.
Aorta, Compression of, in treatment
of post-partum hemorrhage — Dr.
F. P. Elliott, 121, 310.
Aphonia, A suggested treatment for
functional — Dr. C. P. Crouch,
214.
Atheroma, Experimental. 342.
Atkmson, Dr. S. B. — Golden rules
of medical evidence (r.), 364.
Auscultation and percussion — Dr. S.
Gee (r.), 362.
Bacterial origin of general paresis,
348.
Bacteriology, Applied — C. G. Moor
and R. T. Hewlett (r.). 171.
Ball, Dr. J. B.— A handbook of
diseases of the nose and pharynx
Ballantyne, Dr. J. W. — ^Antenatal
pathology and hygiene : the
embryo (r.), 254.
Banti's disease with complications
— Dr. R. Roxburgh, 286.
Bcaslcy's book of prescriptions (r.),
261.
Beddoe, Presentation of portrait of
Dr. John, 288.
Bier's method of producing passive
hyperjemia, 61.
Bigg, H. — Spinal curvatures (r.),
264.
Biographic clinics — Dr. G. M. Gould
(R.), 255.
Blackham, R, J. — ^The care of
children (r.), 75.
Bland-Sutton, J. — Gallstones and
diseases of the bile-ducts (r.),i7o ;
Tumours, innocent and malignant
(R.). 361.
Blood changes in general sarcoma —
Dr. F. G. BushneU, 321.
Blood-glands as pathogenic factors
in the production of diabetes, 57.
Blood pressure. Studies in — Dr. G.
Oliver (r.), 73.
Breast, Cancer of the— W. S. Hand-
ley (r.). 253.
Breast, Excision of, for carcinoma,
344.
Brend, Dr. W. A.— A handbook of
medical jurisprudence and toxi-
cology (r.), 261. '
Bristol General Hospital, Descrip-
tion of new isolation block at, 93,
Bristol Medico-Chirurgical Society,
87, 185, 285, 382.
Bristol, Public health in, 1906-7 — '
Dr. D. S. Davies, 336.
Bristol Royal Infirmary, Proposed
new rules, 272, 368,
British journal of tuberculosis (r.),
263.
Brown and W. T. Ritchie, Drs. J. J.
G. — Medical diagnosis (r.), 262. '
Brunton, • Sir L. — Collected papers
on circulation and respiration
(R.). 171-
26
Digitized by VjOOQIC
386
INDEX.
Buchanan, Dr. A. M. — ^Manual of
anatomy (r.), 251. 354.
BuUen, F. St. J.— Report on
psychiatry, 348.
Bush and Dr. J. A. Nixon, J. P. —
A case of filariasis, 218.
Bushnell, Dr. F. G. — A case of
generalised sarcoma, with blood
changes, 321.
Buxton, Dr. D. W. — Anaesthetics,
their uses and administration (r.),
363.
Calder, Dr. A. B. — Lectures on
midwifery for midwivcs (r.), 171.
Campbell, Dr. H. — On treatment
(r.), 260.
Cancer of the breast — W. S. Hand-
ley (r.), 253.
Carcinoma of breast, 344.
Carter, Dr. A. H. — Elements of
practical medicine (r.), 262.
Carwardine, T. — Report on surgery,
243.
Catalogue (Index-) of the library of
the Surgeon-General's Office,
United States Army (r.), 270.
Catalogue of the pathological mu-
seum of the Manchester Univer-
sity— Dr. J. L. Smith (R.), 364.
Cataract extraction. Healing of
corneal wound in, 249.
Cathcart. Dr. C. W.— The essential
similarity of innocent and malig-
nant tumours (r.), 254.
Cerebral lesions in pregnancy and
parturition — Dr. W. C. Swayne,
209.
Cerebro-spinal fever — Drs. D. S.
Davies and I. W. Hall, 14.
Cerebro-spinal fever, 82.
Cerebro-spinal meningitis. The
etiology and diagnosis of — Dr.
A. W. Taves (r.), 262.
Chapman, Dr. W. L. — The sequelae
of gonorrhoea in both sexes (r.),
265.
Charles, Dr. J. R. — Report on
medicine, 57.
Chest, The Rontgen rays in the
diagnosis of diseases of the —
Drs. H. Walsham and C. H. Orton
(r.), 267.
Children, Aids to the treatment of
diseases of — Dr. J. McCaw (r.),
365.
Children, The care of— R. J. Black-
ham (r.), 75.
Circulation, Collected papers on —
Sir L. Brunton (r.), 171.
Clarke, Dr. J. M. — Cases illustrating
the more unusual complications
of pneumonia, 89, 108 ; Report
on medicine, 341 ; Treatment of
Graves's disease by anti-th3n:eoid
serum and by X-rays, 201.
Climatotherapy and balneotherapy
—Sir H. and Dr. F. P. Weber (r.),
266.
Cod liver oil and tuberculosis —
Dr. J. W. Wells (r.). 271.
Colour phenomena — J. W. Lovi-
bond (r.), 72.
Consciousness, Double — Dr. F. H.
Edgeworth, 186.
Convulsions, 67.
Coombs, Dr. C. — Rheumatic car-
ditis in childhood, 193.
Cooper, R. H. — The uses of X-rays
in general practice (r.). 268.
Corneal wound in cataract extrac-
tion. Healing of, 249.
Cossham Memorial Hospital, 179,
190.
Cotton, Dr. W. — Proportional re-
presentation and the comparison;
of radiographs. 326.
Crichton-Browne, Sir J. — ^The pre-
vention of senility, and a sanitary
outlook (r.), 360.
Crook, Dr. H. E. — High frequency
currents (r.), 257.
Crouch, Dr. C. P. — A suggested
treatment for functional aphonia^
214.
Cuff, I. Stewart and Dr. H. E.—
Practical nursing (r.), 175.
Cunningham, Dr. D. J. [Ed.] — Text-
book of anatomy (r.), 168.
Dalgado, Dr. D. G. — The climate of
Lisbon, Mont Estoril and Cintra
(R.). 173-
David, Dr. M. — Grundriss der orth-
opadischen chirurgie (r.), 265.
Davies, Dr. D. S. — Public health in
Bristol, 1906-7, 336.
Davies and I. W. HaU, Drs. D. S.—
Cerebro-spinal fever, 14.
Davos as health resort (r.), 173.
Deflections and spurs of the nasal
septum, Operations for — Dr.
P. W. Williams, 21.
Dental caries. On— Dr. J. S. Wal-
lace (r.), 175.
Diabetes, Blood-glands as patho-
genic factors in, 57.
Digestive system. Treatment of
diseases of the — Dr. R. Saundby
(R.)» 73.
Digitized by VjOOQIC
INDEX.
387
Dowse, Dr. T. S. — Lectures on
massage and electricity (r.), 268.
Editorial notes, j6, 177, 272, 368.
Edmunds, W. — Sound and rhythm
(R.). 174.
Electricity, medical— Dr. T. S.
Dowse (r.), 268 ; Dr. H. L. Jones
(R.), 266.
Elliott, Dr. F. P.— The value of
compression of the aorta in the
treatment of post-partum hemor-
rhage, 121, 310.
Encyclopedia and dictionary of
medicine and surgery (r.), 259.
Epidemiological Society of London,
Transactions of the (r.), 269.
Estlander's operation for empyema
— Dr. H. S. Ballance, 285.
Evidence, Golden rules of medical —
Dr. S. B. Atkinson (r.), 364.
Eye, Diseases of the — Dr. C. H. May
and C. Worth (r.), 172.
Eye, Syphilitic affections of the, 247.
Paeces, 68.
Filariasis, Case of — J. P. Bush and
Dr. J. A. Nixon, 218.
Food-fads and faddists, 368.
Foster, Sir Michael, 81.
Free, John, 276.
■Gallstones and diseases of the bile-
ducts — J. Bland-Sutton (r.), 170.
Gee, Dr. S. — Auscultation and per-
cussion (r.), 362.
•Gonorrhoea, The sequelae of — Dr.
W. L. Chapman (r.), 265.
•Gould, Dr. G. M. — Biographic
clinics (r.), 255.
•Gout— Dr. A. P. Luff (r.), 260.
•Graves's disease treated by anti-
thyreoid serum and by X-rays —
Dr. J. M. Clarke, 201.
•Griffiths, L. M.— The Medical Read-
ing Society, Bristol, 222.
•Groves, E. W. H. — Report on sur-
gery, 61 ; Some remarks on spinal
anaesthesia, as based upon the
personal observation of thirty
^ cases, 305.
"Guy's hospital reports (r.), 271. .
Hall, Dr. I. W.— Report on medi-
cine, 236; Report on pathology, 67.
JIall, Drs. D. S. Davies and I. W.—
Cerebro-spinal fever, 14.
Handley, W. S. — Cancer of the
breast and its operative treat-
ment (r.), 253.
Herman, Dr. G. E. — Diseases of
women (r), 366; First Imes in
midwifery (r.), 362.
Hernia, Retro-peritoneal — B. G. A.
Moynihan (r.), 75.
Herringham, Dr. W. P.— On
physical training in schools (r.),
174.
Hewitt, Dr. F. W. — Anaesthetics
and their administration (r.),
362.
Hewlett, C. G. Moor and R. T.
— Applied bacteriology (r.),
171.
High frequency currents — Dr. H. E.
Crook (r.), 257.
Horsfall, T. C. — The influence on
national life of military training
in schools (r.), 174.
Hyperaemia, Bier's method of pro-
ducing passive, 61.
Hyperleucocytosis. 350.
Hypertension , 153.
Infectious diseases, Nursing of —
Dr. F. J. Woollacott (r.), 176.
Inflammation — Dr. J. G. Adami
(R.). 355-
Internal organs. Indications for
operation in disease of the —
Dr. H. Schlesinger (r.), 70.
Intestine, Two cases of ruptured —
H. F. Mole, 38.
Jones, Dr. H. L. — Medical elec-
tricity (r.), 266.
Kendall, Obituary notice of Herbert
W., 90.
Klein, Dr. E. — Studies in the bac-
teriology and etiology of oriental
plague (r.), 361.
Knee-joint, A new method of fixa-
tion in excision of the — E. W. H.
Groves, 88.
Latham, Dr. A. — Pulmonary con-
sumption (r.), 364.
Library of the Bristol Medico-
Chirurgical Society, 85, 182, 283:,
379.
Lisbon, The climate of — Dr. D. G.
Dalgado (r.), 173.
Liver, Acquired angioma of the —
Dr. A. L. Sheppard, 46.
Local medical notes, 93, 187, 287,
383.
Lovibond, J. W. — An introduction
to the study of colour phenomena
(r.), 72.
Digitized by VjOOQIC
388
INDEX.
Luff, Dr. A. P.— Gout (r.), 260.
Luke, Dr. T. D.— Guide to anaes-
thetics (r.), 364.
Lumba^r puncture as an aid to
diagnosis, 351.
Lupus ,vulgaris, Eighty cases of —
Dr. W. K. Wills, 127.
McCaw, Dr. J. — Aids to the treat-
ment of diseases of children (r.),
365.
McCrudden, F. H. — Uric acid :
chemistry, physiology and path-
ology (r.), 74.
M'Gregor, Dr. A. N. — A system of
surgical nursing (r.), 175.
McKisack, Dr. H. L. — A dictionary
of medical diagnosis (r.), 259.
Marshall, Dr. C. F. — Syphilology
and venereal disease (r.), 70.
Martindale and Dr. W. W. West-
cott, W. — ^The extra pharma-
copoeia (r.), 75.
Massage, Lectures on — Dr. T. S.
Dowse (r.), 268.
Massage, Lessons on — M. D. Palmer
(r.), 268.
May and C. Worth, Dr. C. H.— A
manual of diseases of the eye (r.),
172.
Medical diagnosis — Drs. J. J. G.
Brown and W. T. Ritchie (r.J, 262.
Medical diagnosis, A dictionary of —
Dr. H. L. McKisack (r.), 259.
Medical diagnosis. Aids to — Dr. A.
Whiting (r.), 353.
Medical jurisprudence, A handbook
of— Dr. W. A. Brend (r.), 261.
Medical Reading Society, Bristol —
L. M. Griffiths, 222.
Medicine, Manual of — Dr. T. K.
Monro (r.), 73.
Medicine, Practical — Dr. A. H.
Carter (r.), 262.
Medicine, Reports on — Dr. J. R.
Charles, 57; Dr. J. M. Clarke,
341 ; Dr. I. W. Hall, 236 ; Dr.
G. Parker, 152.
Midwifery, First lines in — Dr. G. E.
Herman (r.), 362.
Midwifery for midwives. Lectures
on — Dr. A. B. Calder (r.), 171.
Miles, A. Thomson and A. — Manual
of surgery (r.), 263.
Military training in schools. In-
fluence on national life of — T. C.
Horsfall (r.), 174.
Milk supply of schools, Inquiry con-
cerning the— Dr. C. E. Shelly (r.),
172.
Minor maladies and their treatment
— Dr. L. Williams (r.), 74.
Mole, H. F. — Two cases of ruptured
intestine, 38.
Monkeys, Tumours and tubercle in-
►-— W. R. WUliams, 148.
Monro, Dr. T. K.— Manual ot
medicine (r.), 73.
Moor and R. T. Hewlett, C. G. -
Applied bacteriology (r.), 171.
Morton, C. A. — Report on surgery,.
156.
Moynihan, B. G. A. — On retro-
tf»- peritoneal hernia (r.), 75.
Mummery, Dr. P. L. — The sig-
moidoscope {r.), 263.
Muthu, Dr. D. J. C— The sana-
torium treatment of pulmonary
tuberculosis — is it a success ? 50.
Myeolomata and albumosuria.
Multiple — Dr. J. R. Charles,,
89.
Narcolepsy, A case of — Dr. B. M. H..
Rogers, 87, 144.
Nasal septum. Operations for de-
flections and spurs of the — Dr.
P. W. Williams, 21.
Neerlandicorum de arte medica,.
Opuscula selecta (r.), 361.
Nixon, J. P. Bush and Dr. J. A.- --
A case of filariasis, 218,
Nose and pharynx, Diseases of the-
— Dr. J. B. Ball (r.). 173.
Nose -and throat. Treatment of
diseases of the — C. A. Parker (r.) ,.
69.
Nunneley, Dr. F. P. — Aneurysm 01
the abdominal aorta (r.), 353.
Nursing, Practical — I. Stewart and'
Dr. H. E. Cuff (R.), 175.
Nutritional disorders of infancy,.
Treatment of — Dr. R. Vincent.
(R.). 258.
Obituary, 90, 97.
Obstetrics, Report on — Er. W.C.
Swayne, 162.
Ogilvy, Dr. A. — Report on ophthal-
mology, 247.
Oliver, Dr. G. — Studies in blood
pressure (r.), 73.
Ophthalmology, Report on — Dr.
A. Ogilvy, 247.
Orthopadischen chirurgie, Grundriss
der — Dr. M. David (r.), 265.
Orton, Drs. H. Walsham and C. H..
— ^The Rontgen rays in the diag-
nosis of diseases of the. chest (R.).
267.
Digitized by VjOOQIC
INDEX.
38^
Page, F. J. M. — Elements of physics
for medical students (r.), 357.
Palmer, M. D. — Lessons on massage
. (r.), 268.
Paresis, Bacterial origin of general,
348.
Paresis, Change of type in general,
352.
Parker, C. A. — A guide to the
diseases of the nose and throat,
and then: treatment (r.), 69.
Parker, Dr. G. — Report on medicine,
152.
Pathogenic organisms, 83.
Pathogenic streptococci. The, 236.
Pathological demonstrations, 96.
Pathology, Report on — Dr. I. W.
Hall, 67.
Peritonitis, Treatment of general,
243.
Pharmacopoeia, The extra — ^W.
Martindale and Dr. W. Westcott
(R-)» 75-
Philadelphia hospital reports (r.),
263.
Philippine journal of science. The
(R.), 174.
Physical training in schools. On —
Dr. W. P. Herringham (r.), 174.
Physics, Elements of — F. J. M.
Page (R.), 357.
Plague, Bacteriology and etiology of
oriental — Dr. E. Klein (r.), 361.
Pleural effusions, 152.
Pneumonia, Unusual complications
of— Dr. J. M. Clarke, 89. 108.
Post-partum hemorrhage, 162.
Post-partum hemorrhage. The value
of compression of the aorta in —
Dr. F. P. Elliott, 121, 310.
Pregnancy and parturition. Cerebral
lesions in — Dr. W. C. Swayne,
209.
Prescriptions, Beasley's book of (r.),
261.
Prognosis— Dr. P. H. Pye-Smith, i.
Psychiatry, Report on — F. St. J.
BuUen, 348.
Pulmonary consumption — Dr. A.
Latham (r.), 364.
Pulmonary tuberculosis. The sana-
torium treatment of — Dr. D. J.
C. Muthu, 50.
Pye-Smith, Dr. P. H. — Prognosis, i.
Radiographs, Proportional repre-
sentation and the comparison of
—Dr. W. Cotton, 326.
Reinhardt, Dr. C. — Some notes on
stv-racol, 54.
Renal anasarca. Chloride depriva-
tion in the treatment of, 343.
Respiration, Collected papers on.
circulation and — Sir L. Brunton
(r.), 171.
Retro-peritoneal hernia — B. G. A.
Moynihan (r.), 75.
Rheumatic carditis in childhood —
Dr. C. Coombs, 193.
Ritchie, Drs. J. J. G. Brown and
W. T. — ^Medical diagnosis (r.),
262.
Rontgen rays in the diagnosis of
diseases of the chest — Drs. H.
Walsham and C. H. Orton (r.),
267.
Rogers, Dr. B. M. H. — A case of
narcolepsy, 87, 144.
Ruptured intestine. Two cases of —
H. F. Mole. 38.
Sage-femme et de la garde. Le livre
de la — Dr. R. de Seigneux (r.),
176.
St. Bartholomew's hospital reports
(R.). 365.
Sanatorium treatment of pulmonary
tuberculosis — Dr. D. J. C. Muthu,
50.
Sanitary outlook, A — Sir J. Crichton-
Browne (r.), 360.
Sarcoma, Case of generalised, with
blood changes — Dr. F. G. Bush-
nell, 321.
Saundby, Dr. R. — The treatment of
diseases of the digestive system
(R.)» 73-
Savage, Dr. W. G. — The bacterio-
logical examination of water sup-
plies (R.). 355.
Schlesinger, Dr. H. — Indications for
• operation in disease of the internal
organs (r.), 70.
Seigneux, Dr. R. de — Le livre de la
sage-femme et de la garde (r.),
176.
Senility, The prevention of — Sir J.
Crichton-Browne (r.), 360.
Sheen, Obituary notice of Alfred, 90.
Shelly, Dr. C. E. — A preliminary
inquiry concerning the milk supply
of schools (r.), 172.
Sheppard, Dr. A. I^. — Acquired
angioma of the liver, 46.
Sick, Preparations for the :
Adrenalin and chloretone oint-
ment, 376.
Adrenalin and eucaine tablets,
281.
Alaxa, 181
Digitized by VjOOQIC
390
INDEX.
Sick, Preparations for the :
Anaesthetics, " Wellcome " brand,
279.
Aspirin tablets, 283.
Black wash tablets, 376.
Claroma, 283.
Cholelith pill, 376.
Colalin, 83.
Colalin laxative, 83.
Egmol, 376.
** Elixoid " formates compound,
278.
** Elixoid " pine tar compound,
181.
Ernutin, 279.
Formamint tablets, 83.
Formidine, 281, 375.
Grape nuts, 282.
Helmitol tablets, 283.
Heroin hydrochl. tablets, 283.
lodalbin, 281.
Kuhn's suction mask, 374.
Manhu diabetic foods, 378.
Miol, 378.
Nizin, 182.
Nutritive liquid peptone with
creosote, 280.
Pertussin, 282.
Petroleum emulsion, 376.
Phenofax, 84.
Phenol - phthalein compound,
280.
Phytin preparations, 377.
Quinine acetyl-salicylate, 279.
Soloid — Eosin-azur, 85.
Somatose, Liquid, 83.
Tabloids :
Calcium iodo-ricinoleate, 377.
Calcium lactate, 84.
Carbolic acid and slippery elm,
279.
Gingamint, 279.
Guaiacol camphorate, 84.
Pectoral pastilles, 84.
Slippery elm, 279.
Tannigen, 282.
Tannigen tablets, 283.
Theinhardt's food for infants,
377.
Tilia, 282.
Trional tablets, 283.
Triple glycerophosphates with
nuclein, 280.
Veronal tablets, 283.
Sigmoidoscope, The — Dr. P. L.
Mummery (r.), 263.
Skerritt, Obituary notice of Edward
Markham, 97.
Small -pox. Selected essays on
syphilis and (r.), 260,
Smith, Dr. J. L.— Catalogue of the
pathological museum of the Man-
chester University (r.), 364.
Smithsonian institution report (r.),
367.
Society, Bristol Medico-Chirurgical,
87, 185, 285, 382.
Society for the study of disease in
children. Reports of the (r.), 270.
Sound and rhythm — W. Edmunds
(r.), 174.
Spinal anaesthesia, 159.
Spinal anaesthesia. Some remarks on
— E. W. H. Groves, 305.
Spinal curvatures — H. Bigg (r.),
264.
Splenomegalic cirrhosis in a child
aged seven years. Concluding
notes on a case of — Dr. E. C.
Williams, 43, 88.
Stacpoole, F. — Women's health,
and how to take care of it (r.),
266.
Stewart and Dr. H. E. Cuff, I.—
Practical nursing (r ), 175.
Styracol, Some notes on — Dr. C.
Reinhardt, 54.
Surgery, Manual of — A. Thomson
and A. Miles (r.), 263.
Surgery, Reports on — T. Carwar-
dine, 243 ; E. W. H. Groves, 61 ;
C. A. Morton, 156 ; J. Swain, 344,
Surgical nursing, A system of —
Dr. A. N. M'GreRor (r.), 175.
Swain, Dr. J. — Report on surgery,
344-
Swayne, Dr. W. C. — Cerebral lesions
in pregnancy and parturition,
209 ; Report on obstetrics, 162.
Syphilis — Dr. H. Waldo, 289.
Syphilis and small -pox, Selected
essays on (r.), 260.
Syphilitic affections of the eye. 247.
Syphilology and venereal disease —
Dr. C. F. Marshall (r.), 70.
Taste-fibres, Course of, 341.
Taves, Dr. A. W. — The etiology
and diagnosis of epidemic cerebro-
spinal meningitis (r.), 262.
Thomson and A. Miles, A. — Manual
of surgery (r.), 263.
Thyreoid (anti-) serum. Treatment
of Graves's disease by — Dr. J. M.
Clarke, 201.
Treatment, On — Dr. H. Campbell
(r.), 260.
Tubercle in monkevs. Tumours and
— W. R. Willianis, 149.
Tuberculosis, Infection in, 69.
Digitized by VjOOQIC
INDEX.
391
Tumours and tubercle in monkeys
— W. R. Williams, 149.
Tumours, innocent and malignant —
J. Bland-Sutton (r.), 361.
Tumours, The essential similarity
of innocent and malignant —
Dr. C. W. Cathcart (r.), 254.
Tumours, Trauma as a cause of, 68. '
Typhoid, The diagnosis of, 155.
University College, Bristol, Exam-
ination successes, 93, 187, 287,
383 ; Incorporation of medical
school with, 93 ; Medical prize
distribution. 373.
University College Colston Society,
76.
University for Bristol, Professor
Sadler on a, 78.
University ideal, The, 78.
Uric acid — F. H. McCrudden (r.),
74-
Vincent, Dr. R. — Clinical studies in
the treatment of nutritional dis-
orders of infancy (r.), 258.
Waldo, Dr. H.— Syphilis, 289.
Wallace, Dr. J. S. — On the cause and
prevention of dental caries (r.),
Walsham and C. H. Orton, Drs. H.
— The Rontgen rays in the diag-
nosis of diseases of the chest (r.),
267.
Walter, Capt. A. E.— X-rays in
general practice (r.), 268.
Water supplies, The bacteriological
examination of — Dr.W. G. Savage
(R-). 355.
Weber, Sir H. and Dr. F. P.—
Climatotherapy and balneo-
therapy (r.), 266.
Wellcome 's photographic exposure
record and diary (r.), 270.
Wells, Dr. J. W. — ^The influence of
cod liver oil on tuberculosis (r.)^
271.
Westcott, W. Martindale and Dr. W.
— ^The extra pharmacopoeia (r.),
75-
Whiteford, C. H. — Glimpses of
American surgery in 1906 (r.),
264.
Whiting, Dr. A. — Aids to medical
diagnosis (r.), 353.
Williams, Dr. E. C— Concluding
notes on a case of splenomegalic
cirrhosis in a child aged seven
years, 43, 88.
Williams, Dr. L. — ^Minor maladies
and their treatment (r.), 74.
Williams, Dr. P. W. — Operations
for deflections and spurs of the
nasal septum, with special
reference to sub-mucous resec-
tion, 21.
Williams, W. R. — Tumours and
tubercle in monkeys, 149.
Wills, Dr. W. K.— Eighty cases of
lupus vulgaris, 127.
Winsley sanatorium, 372.
Women, Diseases of — Dr. G. E.
Herman (r.), 366.
Women's health, and how to take
care of it — F. Stacpoole (r.), 266.
WooUacott, Dr. F. J. — ^Lectures
upon the nursing of infectious
diseases (r.), 176.
Workmen's compensation act. The,
188.
Worth, Dr. C. H. May and C— A
manual of diseases of the eye (r.),
172.
X-rays in general practice — R. H.
Cooper (R.), 268 ; Capt. A. E.
Walter (r.), 268.
X-rays, Treatment of Graves's
disease by — Dr. J. M. Clarke, 201^
J. W. Arrowsmith, Printer, Quay Street, Bristol.
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